INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Gaudenzia - New Destiny was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in two of nine client records reviewed.
The findings included:
Nine client records requiring complete informed and voluntary consent to release information forms were reviewed on May 15, 2015. The facility failed to ensure that an informed and voluntary consent to release information form was obtained in client records #'s 3 and 9.
Client #3 was admitted to treatment on December 8, 2014 and was still an active client at the time of the inspection. Urine specimen submissions were sent to a urinalysis lab on 2/17/15, 2/18/15, 3/26/15, 4/5/15, and 4/18/15. However, there was no consent form for the release of information to the urinalysis laboratory nor was there a QSOA between the lab and the facility in place.
Client #9 was admitted to treatment on January 20, 2015 and was discharged on April 15, 2015. Urine specimen submissions were sent to a urinalysis lab on 2/17/15, 2/18/15, 3/26/15, and 4/5/15. However, there was no consent form for the release of information to the urinalysis laboratory nor was there a QSOA between the lab and the facility in place.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Informed and voluntary consents will be maintained in order for information to be released. If, and when a client changes any provider of services, clinical staff will ensure that new consents are signed and maintained. Following the site visit of 5/15/2015, all open files were reviewed to ensure the proper consents were completed. One open case lacked the correct consent for drug and alcohol testing. A new consent was signed indicating the correct provider of services. Further, the counselors will review their own client files at least monthly to ensure ongoing compliance. The Program Director (Clinical Supervisor) will review randomly selected files to ensure compliance. This procedure was discussed with clinical staff on 5/5/15 and with all staff at the 6/8/15 staff meeting. The program cirector is responsible for ensuring compliance. The first files will be reviewed before June 30 and thereafter monthly before the last day of the month in conjunction with Quality Assurance review. Completed 6/8/15. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on the review of client records, the facility failed to ensure that a copy of the informed and voluntary consent form for the disclosure of information was offered to the client in three of nine client records reviewed.
The findings included:
Nine client records requiring documentation that the completed informed and voluntary consent to release information forms were offered to the client were reviewed on May 15, 2015. The facility failed to ensure that the informed and voluntary consent to release information form was offered in client records # 4, 5, and 6.
Client #4 was admitted to treatment on March 16, 2015 and was still an active client at the time of the inspection. A release of information to the funding source and a release of information to a government agency were signed on 03/16/2015 and there was no indication or documentation that the client was offered a copy of either consent form as of the date of the inspection.
Client #5 was admitted to treatment on October 6, 2014 and was discharged on February 24, 2015. A release of information to a physician was signed on 10/07/2014 and there was no indication or documentation that the client was offered a copy of the consent form as of the date of the inspection.
Client #6 was admitted to treatment on May 27, 2014 and was discharged on October 23, 2014. A release of information to an alternative housing program was signed on 10/06/2014 and there was no indication or documentation that the client was offered a copy of the consent form as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All consents must have "ACCEPT" or "REFUSE" clearly checked or initialed to indicate client acknowledgement of being offered a copy of the consent. All open files were reviewed and counselors and case manager meet with individual clients to offer them a copy of the consent. At that time clients checked or initialed the form to indicate their preference. Counselors and Case Manager were directed to ensure compliance. A second check to ensure compliance will occur when consents are filed with any out-of-compliance consents returned to the counselor or case manager for correction with the client. This procedure was discussed with all staff at the 6/8/15 staff meeting. Counselors will review consents at least once a month. Program Director (clinical supervisor) will review files randomly to ensure compliance monthly during the Quality Improvement process. Completion date: 6/8/15. |