INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 26, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Wellspan Medical Group 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 obtain a consent to release information form prior to releasing information in three out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #5 was admitted on June 5, 2023 and was discharge on August 28, 2023.
Client #6 was admitted on March 23, 2023 and was discharged on June 14, 2023.
Client #7 was admitted on February 9, 2023 and was discharged on May 12, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director assigned a mandatory LMS on accurate completion of the Release of Information for Substance Use Disorder information to all Front Office and Clinical Staff on November 13, 2023. The due date for the LMS is 12/31/23. Review of Release of Information for Substance Use Disorder was reviewed in an All Staff Meeting on November 28, 2023. LMS module will be added to all new staff hired after this date. Any staff on Leave of Absence will be asked to complete this within their first shift back to work. The Facility Director or Clinical Lead will review new SUD patient charts of previous month for accurate completion of the SUD Release of Information. Individual staff will receive educational coaching by facility director or clinical lead if this information is not included in the audit review. The SUD Release of Information will be filled out correctly to include the specific client information that will be disclosed in 100% of client charts. Monitoring results will be reported monthly to the Quality Management Council by Facility Director or Designee. Corrective actions will be determined effective after 100% compliance for three consecutive reporting periods. |
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
Based on a review of client records, the facility 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 seven out of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Only the signature page was included in the charts for client rights. Individual coaching was completed for front office staff by the office manager on 11/28/23 to those who are scanning patient rights into patient chart. The Facility Director or Clinical Lead will review new SUD patient charts of previous month for accurate scanning of the Client Rights. Individual staff will receive educational coaching if this information is not included in the audit review. Full client rights forms will be signed and included in 100% of client charts. Monitoring results will be reported monthly to the Quality Management Council by Facility Director or Designee. Corrective actions will be determined effective after 100% compliance for three consecutive reporting periods. |
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, the facility failed to provide a complete client record, which is to include follow-up information in three out of three discharged records reviewed.
Client #5 was admitted on June 5, 2023 and was discharge on August 28, 2023.
Client #6 was admitted on March 23, 2023 and was discharged on June 14, 2023.
Client #7 was admitted on February 9, 2023 and was discharged on May 12, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Follow up for patients who are discharged will be completed and documented in patient charts within 30 days. This was reviewed with staff individually and at a staff meeting on 11/28/23. This is also part of onboarding for new clinicians. The Facility Director or Clinical Lead all discharges within the past month for accurate completion of the Client Rights. Individual staff will receive educational coaching if this information is not included in the audit review. Follow up after discharge will be completed within 30 days of 100% of SUD discharges. Monitoring results will be reported monthly to the Quality Management Council by Facility Director or Designee. Corrective actions will be determined effective after 100% compliance for three consecutive reporting periods. |