INITIAL COMMENTS
|
Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, 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 January 6, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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, Renewal Treatment, 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:
|
Plan of Correction
|
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.
|
Observations
Based on the review of client records, the facility failed to obtain informed and voluntary consent forms for the disclosure of information contained in the client record in seven of seven client records.
The facility failed to obtain an informed and voluntary consent to release information in client records # 1, 2, 3, 4, 5, 6 and 7.
Client records # 1, 2, 3, 4, 5, 6 and 7 documented a release for an organization that required the release be revoked in writing and several releases that required the release be revoked in writing or "verbally if necessary".
The consent to release information form states that revocation must be in writing. 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.
These findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Renewal Treatment, Inc. shall obtain informed and voluntary consent forms for the disclosure of information contained in the client records. Renewal Treatment, Inc. is changing our consent to release information form to include a statement that " consent to release information can be revoked at any time with notification from the client/consumer". The requirements for the consent revocation to be in writing or verbal shall be removed. The Clinical Director and Clinical Supervisor have provided instruction to the intake and Counselor staff on this requirement. The Clinical Supervisor shall ensure continual compliance via regular client record review. The Clinical Supervisor has oversight responsibility for this plan of action. This plan of correction is in place. |
709.34 (c) (5) 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:
(5) Outbreak of a contagious disease requiring CDC notification.
|
Observations
Based on the review of administrative information, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving the outbreak of a contagious disease requiring CDC notification.
The facility had an outbreak of a contagious disease. The incident occurred on December 24, 2020. There was no documentation that a written report was filed with the Department.
These findings were reviewed with faculty staff during the licensing process.
|
Plan of Correction
Renewal Treatment, Inc. shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving the outbreak of a contagious disease requiring CDC notification. Renewal Treatment, Inc.'s Clinical Director or VP HR and Compliance shall ensure that an Unusual Incident Reporting Form is completed and filed with the department for all incidents of outbreak of contagious disease. The Clinical Director and VP HR and Compliance reviewed these requirements and will have overall oversight responsibilities for this plan of action. Additionally, the Clinical Director provided training to the Clinical Supervisors on this reporting requirement. The Clinical Supervisors shall report all incidents of contagious disease to both the Clinical Director and VP HR and Compliance who will have reporting responsibilities. This plan of correction is in place. |