INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 26, 2020 through October 27, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Retreat at Lancaster County PA, LLC 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) (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.
|
Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in three of seven client records reviewed.
Client # 2 was admitted to the outpatient activity on June 26, 2020 and was still active at the time of the inspection. There was a consent to release information form to the funding source, signed and dated by the client on June 16, 2020, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5. The information to be released included the history and physical, biopsychosocial assessment, discharge summary, provider notes and consultation reports, test results, prescription regimen and dosing records.
Client # 4 was admitted to the outpatient activity on May 26, 2020 and was discharged on July 2, 2020. There was a consent to release information form to the funding source, signed and dated by the client on May 5, 2020, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5. The information to be released included the history and physical, biopsychosocial assessment, discharge summary, provider notes and consultation reports.
Client # 5 was admitted to the outpatient activity on April 1, 2020 and was discharged on August 17, 2020. There was a consent to release information form to the funding source, signed and dated by the client on April 1, 2020, that allowed for the release of information exceeding the limits established by 4 Pa. Code 255.5. The information to be released included the transitioning continuing care plan, provider notes and consultation reports, counseling logs, test results and reports, HIV/AIDS and prescription records.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
All clinical staff has been retrained on the 4 PA. Code 255.5 (b) by facility director. Moving forward, all clinical staff will be checking releases of information for any patient coming from the inpatient facility to ensure they have the correct limits established by 4 Pa. Code 255.5 (b). New releases of information will be made as needed. The facility director will be doing chart checks at least two times a week to ensure ongoing compliance with keeping client identifying information within the limits established by 4 Pa. Code 255.5 (b) on all releases of information.
Deficiency will be corrected in active patient's chart on November 24th, 2020. |
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).
|
Observations
The facility failed to document the dated signature of the client on release of informed and voluntary consent to release information forms in two of seven client records reviewed.
Client #5 was admitted to the outpatient activity on April 1, 2020 and was discharged on August 17, 2020. The release of information form to the funding source was signed and dated by the witness on April 1, 2020.
Client #6 was admitted to the outpatient activity on July 1, 2020 and was discharged on August 28, 2020. The release of information forms to the funding source and the probation officer were signed and dated by the witness on July 1, 2020.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Moving forward to ensure that patients can sign consents from a remote site when conducting telehealth appointments, we will be working with electronic signatures within the EMR, or consents will be emailed to patient to be signed and emailed back to clinical staff. If consents are emailed, once the clinical staff receives the consents they will be scanned into the patient chart. If there is a lack of access to technology, the patient will be mailed their consents via USPS to be signed by the patient, then returned to facility via USPS. These will then be scanned into the patient charts. Chart checks will be completed at least two times a week by the facility director to ensure ongoing compliance. |