INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 21, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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, Holcomb Associates, 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 client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.
Client # 7 was admitted on March 12, 2020 and was discharged on October 26, 2020. There was evidence of disclosures to the funding source and to a parole officer during the client's treatment episode; however, there were no consent to release information forms signed by the client documented in the record prior to any of the disclosures.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/15/2021, all staff have been trained on confidentiality and requirement to obtain consents to release information prior to releasing any information to stakeholders. Consents will be obtained for all current and new clients. No information will be released without the client's dated signature and the witness's dated signature on the release of information. Consents to release information will now be obtained prior to or at the initial evaluation by the ACM or clinician completing the evaluation. Clinical Coordinator and Clinical Supervisor will monitor weekly to ensure that we are in compliance with confidentiality laws and regulations. In addition, the Regional Director will monitor monthly to ensure compliance. |
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 client records, the facility failed to document the dated signature of the client on release of information forms in four of seven client records reviewed.
Client #1 was admitted on March 2, 2020 and was still active at the time of the inspection. The release of information form to a support specialist was signed and dated by the witness on March 5, 2020, but it was not signed by the client.
Client #2 was admitted on September 30, 2020 and was still active at the time of the inspection. The release of information forms to the funding source, several government agencies and the emergency contact were all signed and dated by the witness on October 1, 2020, but they were not signed by the client. The release of information forms to the dispensary, the physician, the psychiatrist, and the public defender were signed and dated by the witness on November 5, 2020, but they were not signed by the client.
Client #3 was admitted on September 15, 2020 and was still active at the time of the inspection. The release of information forms to the emergency contacts, the funding source, several government agencies, the attorney and the probation officer were signed and dated by the witness on October 22, 2020, but they were not signed by the client.
Client #6 was admitted on January 17, 2020 and was discharged on September 18, 2020. The release of information form to another treatment provider was signed and dated by the witness on September 10, 2020, but it was not signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 2/15/2021, all staff have been trained on confidentiality and requirement to obtain consents to release information prior to releasing any information to stakeholders. Consents will be obtained for all current and new clients. No information will be released without the client's dated signature on the release of information. Consents to release information will now be obtained prior to or at the initial evaluation by the ACM or clinician completing the evaluation. Clinical Coordinator and Clinical Supervisor will monitor weekly to ensure that we are in compliance with confidentiality laws and regulations. In addition, the Regional Director will monitor monthly to ensure compliance. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include case consultation notes, in three of seven client records reviewed.
Client # 5 was admitted on November 12, 2019 and was discharged on July 8, 2020. There were no case consultation notes documented in the client record.
Client #6 was admitted on January 17, 2020 and was discharged on September 18, 2020. There were no case consultation notes documented in the client record.
Client # 7 was admitted on March 12, 2020 and was discharged on October 26, 2020. There were no case consultation notes documented in the client record.
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Plan of Correction
Regional Director and Clinical Coordinator developed a more robust tracking mechanism to ensure timely completion of case consultation notes that is in line with the agencie's policies and procedures. Effective 2/15/2021, the Clinical Coordinator and Clinical Supervisor will monitor timely submissions of case consultation notes for all clients. The Regional Director will provide oversight monthly to ensure compliance with case consultation notes. Regional Director and Clinical Coordinator will review policy with all clinical supervisors completing case consultation notes to ensure timeliness of completion. |