INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 30, 2020 through January 31, 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, Wellspan Philhaven 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
During a licensing inspection conducted on January 30, 2020 through January 31, 2020, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. A counseling session could be heard in the hallway of the facility because the sound machine was not in use during the session.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A maintenance ticket was immediately placed to fix a broken white noise machine mounted in the ceiling outside our check-out offices. Additionally, 30 noise machines were ordered and have been received. They have been placed in each therapy office, and in our front waiting room area. As of today, 2/11/2020, this plan of correction is now in place. |
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
During a licensing inspection conducted on January 30, 2020 through January 31, 2020, it was determined that the project failed to obtain informed and voluntary consent from the client in two out of seven records reviewed.
Client #2 was admitted on July 22, 2019 and was an active client at the time of the inspections. This client received billable treatment services from the facility on July 22, 2019, August 5, 2019, August 19, 2019 and August 26, 2019; however, a consent to release information to the funding source had not been documented and signed by this client until September 30, 2019.
Client #4 was admitted on June 4, 2019 and was discharged on November 19, 2019. A consent to release information to the funding source was not documented in this client's record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A meeting was held with support staff on February 3, 2020 to review the need to obtain informed voluntary consent from clients for disclosure, including insurance. Staff were instructed to ensure the insurance consent always matched the current insurance/billed insurance on file. A review of applicable signed consents will be added to our internal audit process beginning 3/1/2020. Additionally, our billing manage was made aware that in order to bill insurance for SUD services, billers should be checking for an insurance ROI. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
During a licensing inspection conducted on January 30, 2020 through January 31, 2020, it was determined that the project failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in client record # ' s 1, 2, 3, 4, 5, 6, and 7.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 2/27/2020, a meeting was held with senior leaders from WellSpan, including our health information management department, our Director of Addiction Services, Director of Outpatient Services, Clinic Directors and the Senior Clinic Director for Edgar Street. We reviewed the DDAP regulations, our internal policies and workflows. Temporarily, on 2/17/2020, a client rights form was added to our patient paperwork workflow for all clients coming into our program for SUD services. This Client Rights form contains the information found in DDAP regulations, including the specific language regarding client rights. Clients now sign off on this form and it is scanned into their medical record. Any client discharged prior to implementation of this form did not sign the form, but all other clients still active in treatment are receiving and signing this form, which is then scanned into the record, at their next appointment. At the meeting held on 2/27/2020, we reviewed the form, our privacy practices and the regulations to ensure this form met all the requirements. It was decided that we would continue to use this form to meet this regulation, informing clients of their rights. Additionally, it was decided that a smaller group would meet to focus on client rights and confidentiality across WellSpan Philhaven for SUD and MH services. In the meantime, we will continue use of the client rights form and ensure any future process continues to satisfy these regulations. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
During a licensing inspection conducted on January 30, 2020 through January 31, 2020, it was determined that the project failed to inform clients that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Additionally, the project failed to notify clients that reasons for removing sections shall be documented in the record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 2/27/2020, a meeting was held with senior leaders from WellSpan, including our health information management department, our Director of Addiction Services, Director of Outpatient Services, Clinic Directors and the Senior Clinic Director for Edgar Street. We reviewed the DDAP regulations, our internal policies and workflows. Temporarily, on 2/17/2020, a client rights form was added to our patient paperwork workflow for all clients coming into our program for SUD services. This Client Rights form contains the information found in DDAP regulations, including the specific language regarding client rights. Clients now sign off on this form and it is scanned into their medical record. Any client discharged prior to implementation of this form did not sign the form, but all other clients still active in treatment are receiving and signing this form, which is then scanned into the record, at their next appointment. At the meeting held on 2/27/2020, we reviewed the form, our privacy practices and the regulations to ensure this form met all the requirements. It was decided that we would continue to use this form to meet this regulation, informing clients of their rights. Additionally, it was decided that a smaller group would meet to focus on client rights and confidentiality across WellSpan Philhaven for SUD and MH services. In the meantime, we will continue use of the client rights form and ensure any future process continues to satisfy these regulations. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
During a licensing inspection conducted on January 30, 2020 through January 31, 2020, it was determined that the project failed to inform clients that the clients have the right to appeal the decision to limit access to their records to the director.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
On 2/27/2020, a meeting was held with senior leaders from WellSpan, including our health information management department, our Director of Addiction Services, Director of Outpatient Services, Clinic Directors and the Senior Clinic Director for Edgar Street. We reviewed the DDAP regulations, our internal policies and workflows. Temporarily, on 2/17/2020, a client rights form was added to our patient paperwork workflow for all clients coming into our program for SUD services. This Client Rights form contains the information found in DDAP regulations, including the specific language regarding client rights. Clients now sign off on this form and it is scanned into their medical record. Any client discharged prior to implementation of this form did not sign the form, but all other clients still active in treatment are receiving and signing this form, which is then scanned into the record, at their next appointment. At the meeting held on 2/27/2020, we reviewed the form, our privacy practices and the regulations to ensure this form met all the requirements. It was decided that we would continue to use this form to meet this regulation, informing clients of their rights. Additionally, it was decided that a smaller group would meet to focus on client rights and confidentiality across WellSpan Philhaven for SUD and MH services. In the meantime, we will continue use of the client rights form and ensure any future process continues to satisfy these regulations. |