This report is a result of an on-site licensure renewal inspection conducted on December 17-18, 2013, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie 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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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent form for the release of client information and/or exceeded the restrictions imposed at 4 Pa. Code, subsection 255.5 (b) in seven out of thirteen client records.
The findings include:
4 PA Code, subsection 255.5 (b) specifies that information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials....is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Thirteen client records requiring documentation of informed and voluntary consent to release client information forms were reviewed on December 17-19, 2013. The facility failed to obtain an informed and voluntary consent form for the disclosure of client information and/or exceeded the restrictions imposed at 4 Pa. Code 255.5 (b) in client records # 1, 11, 13, 15, 18, 20, and 21.
Client # 1 was admitted on 8/6/13. The facility failed to obtain an informed and voluntary consent to release client information form as the record included a blank "Authorization To Allow for Release of Information" form that was signed by the client. The consent to release information form did not include the name of the person, agency or organization to whom disclosure is made, the specific information to be disclosed, the purpose of the disclosure, the dated signature of witness, or the expiration date of the consent.
Clients # 11, 13, 15, 20, and 21 received treatment funding from the county. Records # 11, 13, 15, 20 and 21 included an "Authorization To Allow for Release of Information" form for the client's funding and monitoring source. The facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 (b) as the "Authorization To Allow for Release of Information" forms permitted for the release of assessment results, records of attendance, treatment plans and summaries of treatment, discharge summaries and aftercare plans.
Client # 18 was admitted on 4/2/13 and was still an active client on the date of inspection. The record included an "Authorization To Allow for Release of Information" form for a government agency that was signed by the client. The facility failed to adhere to the restrictions imposed at 4 Pa. Code 255.5 (b) as the "Authorization To Allow for Release of Information" form permitted for the release of assessment results, record of attendance and urine screens.
The Facility Director confirmed the findings.
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Plan of Correction
We have scheduled a mandatory confidentiality training for all staff to review applicable confidentiality laws, including limitations of 255.5. This training will also include examples of how to properly complete a release form and instructions for having a release form signed only after it has been filled in completely. We have also revised our release of information forms for those entities such as judges, probation/parole officers, governmental officals, insurance companies, who may only receive limited information under 255.5, to include only those 5 items identified.
Additionally, completed release of information forms will be reviewed upon completion by the immediate supervisor to ensure accuracy and completion.
The staff training will be conducted by the Clinical Director. The Clinical Director will also be responsible for monitoring the review process by the supervisors.
Client #1 is not active in treatment and release was not necessary as not information was provided to entitiy on release.
Clinets #13, 20, and 21 are no longer active in treatment.
Clients # 11, 15 and 18 are still active and the clinical supervisor will get an updated release form signed. |
Observations
Based on a review of client records, the facility failed to document the proposed type of supportive services on the individual treatment and rehabilitation plan in four of twelve client records.
The findings include:
Twelve client records were reviewed on December 17-19, 2013. The facility failed to document the proposed type of supportive services on the individual treatment and rehabilitation plan in client records # 1, 12, 14, and 16.
The Facility Director did not dispute the findings.
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Plan of Correction
To each treatment plans, we will attach a support service/case coordination form which identifies support services to which the client is being referred to assist with reaching their treatment plan goals. Clinical Supervisors will review and sign each treatment plan and ensure that the support services form is complete and attached.
The Clinical Director will monitor this process for adherence and completion. |