INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Luke's Hospital-Sacred Heart Campus 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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710.23(a) LICENSURE Patient Records
§ 710.23. Patient records.
(a) In addition to the requirements contained in § 115.32 (relating to contents), the patient ' s medical record shall contain a drug and alcohol support plan, follow-up information, and an aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to ensure the patient record contained follow-up formation in two of four applicable patient records reviewed.
Patient #4 was admitted on June 19, 2023 and was discharged on June 21, 2023. There was no follow-up information documented in the record at the time of the inspection.
Patient #6 was admitted on October 26, 2023 and was discharged on October 27, 2023. 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
1. Deficiency 710.23 A
a. Based on review of the patient record, the facility failed to ensure the patient record contained follow-up information in 2/4 applicable patient record reviewed.
i. ACTION: Detox Counselors, nursing, and provider staff received updated education on 12/12/2023 regarding required documentation of support plan, follow-up care, and aftercare plan, if applicable for all patients discharged from the department.
ii. Purpose of,
iii. COMPLIANCE MONITORING: Counselor Supervisor and program director to collectively perform 10 random chart audits per month to validate completion of follow up care documentation. Goal 100% compliance. Continue monthly until goal reached 3 consecutive months. Then reduced to quarterly audits.
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710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of patient records, the facility failed to ensure that all the required elements for a written consent to release information, per the Federal drug and alcohol regulations contained in 42 CFR Subpart C were present on releases of information in two of seven patient records reviewed.
Patient #2 was admitted on November 11, 2023 and was still active at the time of inspection. There were release of information forms to a funding source and emergency contact, signed by the patient on November 12, 2023, that did not include the specific information to be released. Additionally, there was a release of information form to an emergency contact, signed by the patient on November 11, 2023, that did not include the purpose of the disclosure.
Patient #7 was admitted on February 16, 2023 and was discharged on February 18, 2023. There was a release of information form to an emergency contact, signed by the patient on February 17, 2023, that did not include the specific information to be released.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
2. Deficiency 710.23 B
a. Based on a review of the patient records, the facility failed to ensure that all the required elements for a written consent to release information, per the Federal drug and alcohol regulations contained in 42 CFR Subpar C, were present on releases of information in 2/7 patient records reviewed.
i. ACTION: Detox Counselors, nursing, and provider staff received updated education on 12/12/2023 regarding the Release of Information requirements inclusive of documentation completion standards and funding source
ii. COMPLIANCE MONITORING: Counselor Supervisor and program director to collectively perform 10 random chart audits per month. Goal 100% compliance. Continue monthly until goal reached 3 consecutive months. Then reduced to quarterly audits.
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