INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 11, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Resources for Human Development 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in six of fourteen client records reviewed.
Client # 2 was admitted on March 23, 2020 and was discharged on April 2, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 5 was admitted on December 4, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 7 was admitted on December 7, 2020 and was discharged on January 15, 2021. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 8 was admitted on January 13, 2020 and was still active at the time of the inspection. The release of information form to the funding source, signed by the client and witness on January 13, 2020, expired on January 13, 2021. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no new consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 9 was admitted on February 20, 2020 and was still active at the time of the inspection. The release of information form to the funding source, signed by the client and witness on February 20, 2020, expired on February 20, 2021. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no new consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 10 was admitted on July 15, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on releases of information. Verbal consent to release this information was provided by clients.
A list of clients seen for OP services and IER services from 03/11/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, releases of information will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures.
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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
Based on a review client records, the facility failed to document the dated signature of the client on release of information forms in seven of fourteen client records reviewed.
Client # 2 was admitted on March 23, 2020 and was still active at the time of the inspection. The release of information forms to the funding source, another treatment provider, the emergency contact, the correctional facility and the parole officer were signed and dated by the witness on March 23, 2020, but all of the release forms were not signed by the client.
Client # 5 was admitted on December 4, 2020 and was still active at the time of the inspection. The release of information forms to the funding source, other treatment providers, the emergency contact and the correctional facility were signed and dated by the witness on December 4, 2020, but all of the release forms were not signed by the client.
Client # 7 was admitted on December 7, 2020 and was discharged on January 15, 2021. The release of information forms to the funding source, other treatment providers, the correctional facility and the parole officer were signed and dated by the witness on December 7, 2020, but all of the release forms were not signed by the client.
Client # 8 was admitted on January 13, 2020 and was still active at the time of the inspection. The release of information forms to the funding source, other treatment providers, the emergency contact, the drug court, government agencies and the parole officer were signed and dated by the witness on December 23, 2020, but all of the release forms were not signed by the client.
Client # 9 was admitted on February 20, 2020 and was still active at the time of the inspection. The release of information forms to the funding source, another treatment provider, the emergency contact, the drug court, and government agencies were signed and dated by the witness on February 17, 2021, but all of the release forms were not signed by the client.
Client # 10 was admitted on July 15, 2020 and was still active at the time of the inspection. The release of information forms to the funding source, another treatment provider, the emergency contact, the lawyer, the parole officer, and a government agency were signed and dated by the witness on July 15, 2020, but all of the release forms were not signed by the client.
Client # 13 was admitted on September 23, 2020 and was discharged on January 14, 2021. The release of information forms to the funding source, another treatment provider, the emergency contact, the primary care physician, and government agencies were signed and dated by the witness on September 23, 2020, but all of the release forms were not signed by the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on releases of information. Verbal consent to release this information was provided by clients.
A list of clients seen for OP services and IER services from 03/11/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, releases of information will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's August 2019 through February 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an April 21, 2020 event that required the presence of police and/or ambulance personnel at the facility.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Director will submit incident report via DDAP Event Reporting System for the incident referenced in citation.
Director and Assistant Director will ensure that all unusual incidents are reported to DDAP within 3 business days following an event that requires the presence of police and/or ambulance personnel at the facility. A monthly review of incident reports will occur to ensure that any incidents not reported are submitted via the Event Reporting System. |