INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 30, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Penn Foundation Inc. 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) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
The facility failed to document the dated signature of the client on release of information forms in one of seven client records reviewed.
Client #3 was admitted on January 14, 2020 and was still active at the time of the inspection. The release of information forms to several family members were signed and dated by the witness on January 14, 2020 and August 25, 2020.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As part of our COVID emergency declaration operations signatures were not obtained and noted as so. Beginning 10/16/2020 these releases will be mailed and requested signature from the client. Moving forward all releases will be mailed when service is provided over telehealth in order to gain signatures and prevent a barrier to accessing treatment. The Director of Outpatient services will coordinate and monitor this process. |