INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on July 7, 2021 through July 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Aldie Counseling Center 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) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of fourteen client records reviewed. Additionally, the facility failed to document the specific information to be released on consent to release information forms in one of fourteen client records reviewed.
Client #3 was admitted into the methadone maintenance level of care on June 17, 2021 and was active at the time of inspection. There were consent to release information forms to a funding source, a physician, and a government agency, all signed and dated by the client, that did not indicate the specific information to be disclosed.
Client #9 was admitted into the outpatient level of care on February 19, 2021 and was active at the time of inspection. There was a consent to release information form to a probation officer, signed and dated by the client, that allowed for all urine screens, psychiatric records, and diagnostic survey information to be disclosed, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #11 was admitted into the outpatient level of care on March 31, 2021 and was discharged June 15, 2021. There was a consent to release information form to a government agency, signed and dated by the client, that allowed for all urine screens, and psychiatric record information to be disclosed, all of which exceeds the limits established by 4 Pa. Code 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The CEO addressed the matter dealing with release of information and the limits of 4 PA Code 255.5 at a full staff meeting on July 21st. The issue was also discussed at a management meeting held on July 12th.
To reinforce the correct action needed, the clinical director will conduct a training at the clinical team meeting on August 5th. Thereafter the matter of properly completing the release forms within the limits of 255.5 will be reviewed regularly in group and individual supervision.
The actual release form has been modified in the new EHR system to further assist in the proper completion of the form within regulations. The periodic reviews of the forms will be part of regular supervision and monitored by the clinical director. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify clients, in writing, of the decision to involuntarily terminate the client from treatment in one of one applicable client records reviewed.
Client #7 was admitted on February 25, 2021 and was discharged June 21, 2021.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The CEO addressed the deficiency with the management team on July 12th and the full staff on July 21st. The Clinical Director, in consultation with the CEO and Assistant Clinical Directors, has developed a procedure to notify involuntary terminated in writing of the decision. Part of this process will involve maintaining current email addressed for each client, as in some instances notification via regular mail may not be the best option. The process will be implemented and overseen by the Clinical Director with assistance from the Assistant Clinical Directors in supervision with therapists. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to ensure that clients are given the opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.
Client #7 was admitted on February 25, 2021 and was discharged June 21, 2021.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The CEO reviewed the deficiency with the management team on July 12th. The Clinical Director will provide further instruction at the clinical team meeting on August 5th. The requirement will also be added as part of a form on the new EHR system. As such the primary therapist will be required to mark the record that the client was given the opportunity to request consideration.
Compliance will be monitored by the clinical supervisors as part of regular supervision. |
715.23(b)(5) LICENSURE Patient records
(b) Each patient file shall include the following information:
(5) The results of all annual physical examinations given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician.
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Observations
Based on a review of client records, the facility failed to document, in the patient record, the results of an annual physical examination given by the narcotic treatment program which includes an annual reevaluation by the narcotic treatment physician in one of two applicable patient records reviewed.
Patient #2 was admitted on May 18, 2020 and was active at the time of inspection. The last documented physical exam was the physcial exam completed during admission on May 18, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The CEO reviewed the deficiency with the management team on July 12th. The failure to document the annual physical examination was likely due to a change in protocol during the COVID-19 pandemic. The process has since been revised to track the status of the due dates for annual reevaluations in the EHR. Nursing and support staff are made aware of the dates and the clients are scheduled with the physician in advance of the annual due date. The Clinical Director will reinforce adherence to the requirement at the August 5, 2021 clinical team meeting. Thereafter the issue will be monitored by the clinical supervisors during regular supervision. |