INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on August 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, GPHA-Al Assist Behavioral Health Center 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 #2 was admitted on March 10, 2021 and was active at the time of inspection. There was documentation of billing to the funding source; however, there was no consent form on file prior to the disclosure of information. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
n an effort to address the deficiency associated with standard 709.28 (c) Confidentiality: The project shall contain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Intakes that were completed virtually due to the COVID-19 Pandemic were reviewed for active clients in treatment. Clients that we failed to obtain a written and signed consent for their insurance plan were notified that we need to obtain a consent for their insurance plan.
The Billing department was notified to delay any further billing until consents were signed as needed.
Therapist was notified to verify and ensure that the consent was completed prior to fully engaging in a follow-up visit.
Site Directors and the DA committee are tracking the consents for the insurance plans to notify the billing department immediately upon any changes.
All deficiencies will be resolved by October 29, 2021. This will allow time for clients to be notified, and make arrangements to present to the site to sign consents. Effective October 11, 2021, a revised PDF fillable Insurance Plan consent form was added to the virtual consent package to ensure an easier process for Clients attending a virtual intake session if necessary.
Monitoring will be Ongoing by the DA Committee and Quality Assurance (QA) Department. Audit findings will be reported to Leadership Team, Quality Assurance Department, and Chief Behavioral Health Officer during bi-weekly Leadership meetings to ensure continued compliance. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to keep consent forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) in one of seven client records reviewed.Client #5 was admitted on August 17, 2021 and was active at the time of inspection. There was a consent to release information form to the funding source, signed and dated by the client, that allowed for all intake/admissions information, Plan care recommendations and progress notes to be released, which exceeds the limits established by 4 Pa. Code 255.5.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
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 must be in writing and include, but not be limited to: (2) Specific information disclosed.
In an effort to consistently meet standard 709.28 (c) (2) Licensure Confidentiality. Effective immediately Clients currently active in treatment who have consents that exceed 4 Pa Code 255.5, will be informed that their consent(s) on file will be revoked immediately. If the revoked consent(s) is a consent in which the Clients wants to maintain program communication with the identified source, the Client will be asked to sign a revised copy of the consent. The revised copy of the consent fully meets the above standards. Clients will be informed of the information the program may release with the revised signed informed and voluntary consent, which will be limited to: (1) whether the client is or is not in treatment (2) the prognosis of the client, (3) the nature of the project (4) a brief description of the progress of the client and (5) a short statement as to whether the client has relapsed into drug and alcohol abuse and frequency of such relapse in accordance with 4 Pa Code 255.5. Staff members responsible for completing release of information forms will be required to complete a course on selecting the proper program (Drug and Alcohol) within the EHR system which is designed to automatically limit the information allowed to be released for licensed Drug and Alcohol Programs governed by 709.28 Licensure Confidentiality and 4 Pa Code 255.5.
The Front Desk Supervisor will ensure all front desk staff are retrained by October 22, 2021, and the clinical staff will be formally retrained on October 22, 2021 to reiterate how to properly select the Substance use program, under the consent in the Electronic Health Records, to force limitations for 4 Pa Code 255.5.
In addition, all staff responsible for entering Clients into a treatment and/or changing Clients' program based on presenting symptoms or the Clients self-disclosure of having a Substance Abuse disorder after the Client was previously submitted into the Mental Health Program only will be trained on fully closing the Mental Health episode and Opening a Dual episode with all new Consents indicating the date in-which the program change took place. Prior consents will remain in the MH EHR Episode clinical documentation of care and subject to termination based on the closing out of the MH episode.
However, the Dual EHR Episode will include consents that meet standard 708.28 (c) (2).
The Clinical Supervisor for drug & alcohol services will review all active client records to ensure client records meet 709.28 (c)(2) Confidentiality prior to October 22, 2021.
Monitoring: The Site Director will be responsible to review new client records to ensure release of information forms are within limits established by 4 Pa Code 255.
On-going monitoring will be conducted monthly by the QA Manager and daily by the Front Desk Manager to ensure program compliance. If any infractions are found it will be corrected immediately.
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