INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 9, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Treatment Trends, 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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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.
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Observations
Based on a review of twelve client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one record reviewed. Client #1 was admitted to the Outpatient level of care on February 24, 2022 and was discharged on August 8, 2022. The record did not contain a client signed consent to release information form to the funding source; however, the record contained evidence of billing.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client signed consent to release information forms are the responsibility of the staff member who provides the first service (assessment or intake). After completion of the first service, an encounter in our EMR (AZZLY) is finalized before the client's next scheduled session (group or individual) and automatically sent to the assigned supervisor (Program Director or Clinical Supervisor). The assigned supervisor will complete an audit of that service and the accompanying documentation. If a consent to release information form is missing from the first service, the assigned supervisor will alert the staff member who performed the service via email, to contact the client to obtain signature by sending the release of information form via DocUsign. If client does not have capabilities to complete DocUsign through email, the client will be encouraged to come back to the facility or sign at next scheduled session. A final audit is completed on a biweekly basis by the Program Director or Clinical Supervisor, who use a shared excel spreadsheet that tracks all necessary documentation for each assessment and/or intake. Staff members and Clinical Supervisor will be informed in staff meeting/ supervision. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of twelve client records, the facility failed to ensure that informed and voluntary consent from the client for the disclosure of information forms included the signature of the client in one record reviewed.Client #4 was admitted to the Outpatient level of care on August 22, 2022 and was discharged on December 2, 2022. The record contained a consent to release information form to a government agency signed by the witness on November 8, 2022, that was missing the signature of the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client signed consent to release information forms are the responsibility of the staff member who provides the first service (assessment or intake). Once the appointment is completed and before the client exits the building, the staff member will reopen each signed document to ensure the client's signature has saved. After completion of the first service, an encounter in our EMR (AZZLY) is finalized before the client's next scheduled session (group or individual) and automatically sent to the assigned supervisor (Program Director or Clinical Supervisor). The assigned supervisor will complete an audit of that service and the accompanying documentation. If a consent to release information form is missing a signature, the assigned supervisor will alert the staff member who performed the service via email, to contact the client to obtain signature by sending the release of information form via DocUsign. If client does not have capabilities to complete DocUsign through email, the client will be encouraged to come back to the facility or sign at next scheduled session. A final audit is completed on a biweekly basis by the Program Director or Clinical Supervisor, who use a shared excel spreadsheet that tracks all necessary documentation and their signatures for each assessment and/or intake. Staff members and Clinical Supervisor will be informed in staff meeting/ supervision. |
709.42(a)(4) LICENSURE Prompt delivery of services
709.42. Project management.
(a) The intake project shall have a written procedure for the performance of the following functions:
(4) Prompt arrangement for delivery of the requested services.
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Observations
Based on a review of five client records, the facility failed to ensure the prompt arrangement for delivery of the requested services in two records reviewed.Client #8 was admitted to the Intake, Evaluation, and Referral level of care on March 3, 2022. The record did not contain documentation of the prompt arrangement for the delivery of the requested services. Client #12 was admitted to the Intake, Evaluation, and Referral level of care on October 31, 2022. The record did not contain documentation of the prompt arrangement for the delivery of the requested services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Any individual completing an assessment is to ensure the client is provided arrangements for a prompt delivery of the requested service. Within 2 (two) business days, the assessor will complete the referral by using the preferred form of communication from the receiving facility, (fax, email or phone call). Confirmation of the transmission of records is uploaded into the EMR. Within 7 (seven) business days, the assessor will complete the Referral Follow-Up Form, which indicates the disposition of the referral. The assigned supervisor will complete an audit of the assessment and the accompanying documentation to ensure the prompt delivery of services. Staff members and Clinical Supervisor will be informed in staff meeting/ supervision. |