Observations
The facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in two of eleven client records reviewed during the annual licensing inspection conducted on February 3, 2017. In addition, the project exceeded the limitations imposed at 4 Pa. Code 255.5 (b) in three of eleven client records.
A consent to release information was not documented for the insurance company and the facility disclosed the client's name and diagnosis when requesting prior authorization for medications/counseling services in the following client records.
Client # 3 was admitted into treatment on May 11, 2016 and discharged on December 21, 2016. The disclosure occurred on July 19, 2016.
Client # 7 was admitted into treatment on April 12, 2016 and discharged on June 1, 2016. The disclosure occurred on April 12, 2016.
The following client records were not compliant with 4 Pa. Code 255.5 (b), as the consents to the probation office indicated urine results, results of assessment and treatment goals would be released.
Client # 1 was admitted into treatment on May 12, 2014. The consent was signed by the client on December 29, 2016.
Client # 9 was admitted into treatment on January 13, 2017. The consent was signed by the client on January 13, 2017.
Client # 11 was admitted into treatment on January 16, 2017. The consent was signed by the client on January 16, 2017.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 6, 2016 licensing inspection.
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Plan of Correction
The facility will obtain appropriate Consents to Release Information for client numbers 1, 3,7, 9, and 11 where obtaining the consents are possible and remain relevant. The Clinical Supervisors will develop and provide a training update of the accurate and appropriate completion of consents to release information by Feb 28, 2017. Information to be covered will include appropriate type of release, the appropriate release for funding sources, appropriate choice of information to be released; and limitations of 4 Pa. code subsection 255.5, at a minimum. This will be completed by Feb 28th, 2017. Clinical Supervisor will continue to review and monitor consents and releases through internal chart reviews and supervision. |
Observations
The facility failed to complete an initial drug-screening urinalysis in two of four patient records reviewed during the annual licensing inspection conducted on February 3, 2017.
Patient # 4 was admitted into treatment on October 28, 2016 and discharged on January 19, 2017. The patient was prescribed Suboxone on November 22, 2016. The results of the initial drug-screening urinalysis were not received by the facility until November 25, 2016.
Patient # 5 was admitted into treatment on October 10, 2016 and discharged on January 13, 2017. The patient was prescribed Suboxone on November 1, 2016. The results of the initial drug-screening urinalysis were not received by the facility until November 2, 2016.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 6, 2016 licensing inspection.
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Plan of Correction
The program supervisor will review with all staff the policy and procedure for MAT individuals. The supervisor will stress the importance of initial drug screening urinalysis and random monthly urinalysis must be completed and sent to a lab for MAT individuals receiving Suboxone. It will also be stressed that documentation of receiving confirmation of drug screens must be received prior to the adminisration of suboxone.This will be completed by 2/15/17 |