Observations
Based on a review of client records, the facility failed to comply with the limitations imposed by 4 Pa. Code 255.5 for an informed and voluntary consent for the disclosure of information in five of ten client records reviewed.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, 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
Ten client records requiring documentation of informed and voluntary consents were reviewed on May 21 - 22, 2015. The facility failed to obtain an informed and voluntary consent to release and/or failed to adhere to the limitations imposed by 255.5 in client records, # 1, 2, 3, 4 and 9.
Client # 1 was admitted to the facility on February 27, 2015, and was still an active client at the time of inspection. On February 27, 2015, the facility released client # 1's medication history to an insurance agency. The release of medication to an insurance agency does not comply with the limitations imposed at 255.5.
Client # 2 was admitted to the facility on March 3, 2015, and was still an active client at the time of inspection. The facility failed to comply with the limitations of 255.5. On March 3, 2015, the facility released client #2's medication history to a governmental agency. The release of medication to a government agency exceeds the limitations imposed at 255.5.
Client # 3 was admitted to the facility on March 13, 2015, and was still an active client at the time of inspection. Although a proper consent to release was obtained on March 30, 2015, the facility released information that exceeded 255.5. The facility disclosed client # 3's medications to the governmental agency.
Client # 4 was admitted to the facility on September 16, 2014 and discharged on December 4, 2014. On September 28, 2014, client # 4 signed consent to release to a governmental agency; however, the facility failed to document what information would be released to the Probation Officer.
Client # 9 was admitted to the facility on February 9, 2015 and discharged on May 8, 2015. The facility faxed information which exceeded 255.5 to include client # 9's medication history to a governmental agency on 3/23/15, 3/9/15, 2/25/15 and 2/9/15.
Additionally, the facility failed to ensure the clients confidentiality by having clients, who are not drug and alcohol clients, housed on the following floor of the rehabilitation facility; 6.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Gaudenzia Together House Program will obtain an informed and voluntary consent from the client for the disclosure of specific information disclosed in the chart.
On July 28, 2015 a Record-Keeping training will be facilitated to review the Confidentiality Request to Release Information Form and DOH Policy 709.28(c)and PA Code 255.5. Projects and Coordinating Bodies: Disclosure of Client-Oriented Information.
All Consent to Release Information Forms will be reviewed and monitored during monthly Continuous Quality Improvement (CQI) meetings and to ensure compliance, completion, and timelines by the Program Director.
Persons Responsible:
Division Director
Together House Program Director
Together House Supervisors
Timeframe for Completion: July 28, 2015
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Observations
Based on a physical plant inspection and an interview with the Corporate Director, the facility is licensed to provide drug and alcohol treatment on the 2nd, 3rd, and 6th floor, but the facility was housing non-drug and alcohol clients on the 6th floor.
The findings include:
A physical plant inspection was conducted on May 22, 2015.
Gaudenzia Together House is licensed by the Division of Drug and Alcohol Program Licensure for a maximum client capacity of 67 Inpatient Non-Hospital Drug-Free beds.
Together House clients are housed on the following floors: 2nd, 3rd, and 6th floor.
2nd floor/women's unit - 23 beds counted
3rd floor/men's unit - 21 beds counted
During the inspection of the 6th floor the licensing specialist was informed by the facility staff that the Department of Corrections was utilizing the 6th floor for 26 of their residents whom were not drug and alcohol clients.
Additionally, the facility failed to comply with their drug and alcohol license by exceeding the maximum approved capacity, as there were an additional 3 beds on the 6th floor.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective August 26, 2015, Together House will temporarily reduce the bed capacity from 67 beds to 44 beds. The 44 beds will be located on the 3rd and 4th floors of our building at 1306 Spring Garden Street, Philadelphia PA 19123.
On August 26, 2015, A formal letter outlining the request was emailed and sent via mail to DDAP Acting Division Director and cc'ed to DDAP Licensing Specialist Supervisor .
The Division Director will continue to monitor the beds on the 3rd and 4th floors. Within the next 90 days Gaudenzia will be requesting to increase the bed capacity to 67 per DDAP Licensing Procedures Policy 709.14 (b)(5).
Persons Responsible:
Deputy Director
Division Director
Together House Program Director, Together House Supervisors
Timeframe for Completion: August 26, 2015
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