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 Torre De La Raza 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of one applicable client record reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Client #6 was admitted on December 15, 2023 and was discharged against medical advice on January 5, 2024. There was no documentation indicating the emergency contact was notified the client was discharged against medical advice in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
# Clinical Supervisor will review Client 6 with assigned counselor to discuss importance of notifying the emergency contact after a client is discharged from the facility against medical advice, per the requirement in Licensing Alert 02-21.
Responsible: Clinical Supervisor and Therapists
Date of completion: 09/18/24
#Assigned staff &/or counselors will complete follow up per client familial/emergency contact and/or external provider consent as client indicates in consent, per DDAP and BWC
policy
Responsible: Therapists
Date of completion: 09/18/24
#Supervisors will focus monitor 5 random charts per month for 60 days for respective follow up contact requirements
Responsible: Clinical Supervisor
Date of completion: 09/18/24
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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 document the specific information to be disclosed on a release of information form in one of seven client records reviewed.
Client #1 was admitted on August 12, 2024 and was active at the time of inspection. The release of information form to an emergency contact was signed by the client on August 12, 2024, but the release form did not include the specific information to be disclosed.
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 obtaining the specific information to be disclosed on a release of information form
Responsible Party: Clinical Supervisor and counselor
Completion Date 9/18/24
*Clinical Supervisor will provide a in-service training to all staff regarding the proper completion of consents and what triggers a need for a consents
Responsible Party: Clinical Supervisor Completion Date 9/18/24
*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 Party: Clinical Supervisor Completion Date 9/18/24
*Clinical Supervisor will document outcome of consent chart audit in Performance Improvement report quarterly
Responsible Party: Clinical Supervisor Completion Date: on-going
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in three of seven client records reviewed.
Client #1 was admitted on August 12, 2024 and was active at the time of inspection. The release of information form to an emergency contact was signed by the client on August 12, 2024, but the release form did not include the purpose of the disclosure.
Client #2 was admitted on July 10, 2024 and was active at the time of inspection. The release of information form to a government agency was signed by the client on July 10, 2024, but the release form did not include the purpose of the disclosure.
Client #7 was admitted on February 14, 2024 and was discharged on March 13, 2024. The release of information form to an emergency contact was signed by the client on February 14, 2024, but the release form did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1 Clinical supervisor will client # 1, 2 and 7 with assigned counselor(s) to discuss importance of documenting the purpose of the disclosure on consent forms
Responsible: Clinical Supervisor and Therapists
Date of completion: 09/18/24
2. Clinical Supervisor will provide a in-service training to all staff regarding the proper completion of consents and what triggers a need for a consents and purpose of the disclosure.
Responsible: Clinical Supervisor
Date of completion: 09/18/24
3.Clinical Supervisor will conduct random audits of five (5) charts per clinician each month to validate that staff members are correctly completing consent forms
Responsible: Clinical Supervisor
Date of completion: 09/18/24
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