INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection beginning on February 8, 2021 and concluding on February 19, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health 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 seven client records, the facility failed to document a written informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client #1 was admitted on April 13, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #2 was admitted on October 12, 2020, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #3 was admitted on August 6, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #6 was admitted on June 30, 2020 and discharged on December 2, 2020. " Verbal consent " was observed to be documented on releases of information documented in the client record.
Client #7 was admitted on April 2, 2020 and discharged on July 22, 2020. " Verbal consent " was observed to be documented on releases of information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Beginning April 1st, all intake assessments for new clients will be scheduled in person. All consents will be physically signed at intake. Current, active clients will have new consents submitted with physical signature upon returning to office for their first onsite appointment. For current, active clients who have been conducting telehealth, they will have to attend at least 1 session per month to ensure physical signatures can be obtained and up to date. The corrective action will commence as soon as approved and will take effect as early as April 1, 2021. This will be stipulated by the Program Supervisor and become requirements carried out be direct service staff from April 1, 2021 onward. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the facility failed to document an informed and voluntary consent from the client which included a client signature, for the disclosure of information contained in the client record.
Client #1 was admitted on April 13, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented.
Client #2 was admitted on October 12, 2020, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented.
Client #3 was admitted on August 6, 2020 and is currently active. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented.
Client #6 was admitted on June 30, 2020 and discharged on December 2, 2020. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented.
Client #7 was admitted on April 2, 2020 and discharged on July 22, 2020. " Verbal consent " was observed to be documented on releases of information documented in the client record. There was no client signature documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All consents will be completed at intake in person upon an individual's admission into the Drug and Alcohol program. The electronic health record (Credible) will capture physical signatures containing time and date stamps associated with the physical signature obtained. The same in person stipulation will apply to consents that are completed with active clients upon their return to the office. The corrective action will go into effect April 1, 2021 upon approval. The action will be mandated by the Program Supervisor and carried out by the direct service staff team.
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