INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 1-2, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health - Latrobe 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 and a plan of correction is due on March 28, 2010.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, qualified service organization agreements and an interview with the facility director, the facility failed to document an informed and voluntary consent or a qualified service organization agreement when releasing urine samples to an outside agency for testing in eleven of eleven client records.
The findings include:
Twelve client records were reviewed on March 1-2, 2010. Urine samples were sent to an outside agency in eleven client records. One client did not participate in urine testing. Client records # 1, 2, 3, 4, 5, 6, 7, 8 9, 10 and 11 did not include a signed consent to release information form nor was a qualified service organization agreement in place for the outside agency.
The facility director was interviewed on March 1, 2010 and confirmed the facility did not have a qualified service organization agreement with the agency that conducts urine testing. The facility director also confirmed that informed and voluntary consents had not been completed for clients who were participating in urine testing. The facility director reported a qualified service organization agreement will be obtained with the agencies that provide this testing for the facility.
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Plan of Correction
Project Director will obtain a Qualified Service Organization Agreement with all testing companies for the purpose of releasing drug testing samples and bloodwork. Clinical Supervisor will train staff on use of Consent to Release Information for appropriate laboratory testing companies until the QSOA is signed and received by Facility.
It shall be the responsibility of the Project and Facility Directors to obtain and maintain all QSOAs with testing companies for drug testing and bloodwork. It shall be the responsibility of the Project and Facility Director to insure ongoing compliance with this regulation through yearly reviews of all QSOAs.
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709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records and an interview with the clinical supervisor, the facility failed to document follow up contact in four of four outpatient client records.
The findings include:
Eight outpatient client records were reviewed on March 1-2, 2010. Four of the client records reviewed required a six month follow up contact, per agency policy. The facility did not document follow up contact in client records # 6, 7, 8 and 9.
Client #6 was admitted on April 28, 2009 and discharged on July 16, 2009. Follow up contact was due by January 16, 2010. There was no documentation of follow up contact in client record #6.
Client #7 was admitted on July 1, 2009 and discharged on July 27, 2009. Follow up contact was due by January 27, 2010. There was no documentation of follow up contact in client record #7.
Client #8 was admitted on March 6, 2009 and discharged on June 12, 2009. Follow up contact was due by December 12, 2009. There was no documentation of follow up contact in client record #8.
Client #9 was admitted on March 2, 2009 and discharged on July 23, 2009. Follow up contact was due by January 23, 2010. There was no documentation of follow up contact in client record #9.
An interview with the clinical supervisor took place on March 1, 2010 at approximately 12:10 PM. The clinical supervisor confirmed that there was no follow up documentation in the aforementioned client records.
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Plan of Correction
Clinical Supervisor will train newly hired clerk-typist on policy and procedure of follow-ups at 6 months post discharge. Clerk-typist begins employment on April 1, 2010.
It shall be the responsibility of the Clinical Supervisor to monitor all 6 month discharges to insure follow-up letters are completed and insure compliance with this regulation and agency policy and procedure. |