INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard 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 # 1 was admitted on May 21, 2024 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
# Clinical Supervisor will review client #1 with assigned counselor to discuss importance of completing an informed and voluntary consent to release information form prior to the disclosure of information. Client treatment complete prior to facility awareness of need to correct ROI i.e.no consent to release information. If, client# 1 readmits to treatment facility will review past ROI's if any and create new ROI's as need and client will sign form(s)
Responsible: Clinical Supervisor and Therapists
Date of completion: 09/18/24
*Clinical Supervisor will provide an in-service training to all staff regarding the importance of completing any needed informed and voluntary consent to release information with client and sign all fields on forms upon admission to prevent reoccurrence of deficiency
Responsible: Clinical Supervisor and Therapists
Date of completion: 09/18/24
*Clinical Supervisor will conduct random audits of five (5) charts per clinician each month to validate that staff by members are correctly completing consent forms
Responsible: Clinical Supervisor
Date of completion: 09/18/24
*Clinical Supervisor will document outcome of consent chart audit in Performance Improvement report quarterly
Responsible: Clinical Supervisor
Date of completion: 09/18/24
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of client consent to release information forms were offered to the client in two of seven client records reviewed.
Client # 3 was admitted on May 2, 2024 and was still active at the time of the inspection. Release of information forms to a funding source and a government agency were signed by the client on May 2, 2024, but there was no documentation that a copy of either consent form was offered to the client.
Client # 5 was admitted on December 6, 2023 and was discharged on June 28, 2024. A release of information form to an emergency contact was signed by the client on December 6, 2023, but there was no documentation that a copy of the consent form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
# Clinical supervisor will client # 3 and 5 with assigned counselor(s) to discuss importance of ensure a copy of a consent to release information form was offered to the client. Client# 3 ROI was completed prior to discharge with the assigned counselor. Client #5 was discharged prior to facility becoming aware that a copy of client's consent to release information form was not offered.
Responsible: Clinical Supervisor and counselor
Date of completion: 09/18/24
# Clinical supervisors will provide supervision and an a in -service on consents requirements per DDAP regulation to prevent reoccurrence
Responsible: Clinical Supervisor
Date of completion: 09/18/24
# Clinical supervisor will review consent/ROI forms to assure forms contain required client offer of copy
on utilized form check box
Responsible: Clinical Supervisor
Date of completion: 09/18/24
#. Clinical Supervisor will document outcome of consent audits in Performance Improvement report
Responsible: Clinical Supervisor
Date of completion: on-going
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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 maintain a complete client record, which is to include follow-up information, in three of four applicable client records reviewed.
Client # 5 was admitted on December 6, 2023 and was discharged on June 28, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client # 6 was admitted on March 28, 2024 and discharged on June 28, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client # 7 was admitted on February 25, 2024 and discharged on April 20, 2024. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
# Clinical supervisor will client # 5,6, and 7 with assigned counselor(s) to discuss importance of client records discharge procedures: follow-up
Responsible: Clinical Supervisor and counselor
Date of completion: 09/13/24
# Clinical supervisors will provide supervision related to inputting and scanning information 30 days after discharge of all documentation of follow-up into the EHR per Follow up policy 730.115
Responsible: Clinical Supervisor
Date of completion: 09/13/24
*Clinical Supervisor will conduct random audits of five (5) charts per clinician each month to validate that staff maintaining client records discharge procedures: follow-up
Responsible: Clinical Supervisor
Date of completion: 09/18/24
#. Clinical Supervisor will document outcome of EHR for follow-up audits in Performance Improvement report
Responsible: Clinical Supervisor
Date of completion: on-going
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