INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on February 24 - 25, 2021 staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center Inc./Vandergrift 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:
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Plan of Correction
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of the facility's annual reports, the facility failed to provide documentation the January - December 2019 annual report was made available to the public.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The annual report for 2019 will be made available to the public utilizing local advertising with the annual report for 2020. On or before May 1, 2021. The facility director will be responsible to ensure that this annual report,as well as, future annual reports will be made available to the public each year, as required. |
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.
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Observations
Based on a review of client records, the specific information documented on the consent to release information form exceeded the limitations imposed at 4 Pa. Code in 255.5 in five of eight client records reviewed on February 24 - 25, 2021.
The consents for the funding entity and a government agency in the following records indicated the specific information to be released included: financial information, audit compliance documents and compliance resolution documents.
Client # 2 was admitted June 3, 2020 and discharged August 27, 2020. A consent for the funding entity was documented June 3, 2020.
Client # 4 was admitted August 8, 2020. A consent for the funding entity was documented August 8, 2020.
Client # 5 was admitted June 11, 2020. Consents for the funding entity and a government agency were documented June 11, 2020.
Client # 6 was admitted April 17, 2020. Consents for the funding entity and a government agency were documented April 9, 2020.
Client # 8 was admitted April 27, 2016. Consents for the funding entity and a government agency were documented April 25, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RHJ has a standardized release of information for the funding and government entities. The form was updated to include only the items that did not exceed the limitations of 4 Pa. Code 255.5. Both the form and the Pa. Code were reviewed with staff on 3/3/2021 and staff were instructed to review the updated release with all clients who receive funding and to request that the updated release of information be signed. The updated release of information will then be placed in the clinical record. In order to ensure future compliance the clinical supervisor will conduct random chart audits to ensure that the releases of information do not exceed 255.5. |