INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 17, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ponessa 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in seven out of seven records reviewed.Client #1 was admitted on January 10, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #2 was admitted on March 21, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #3 was admitted on July 31, 2023 and discharged on September 13, 2023. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #4 was admitted on August 21, 2023 and discharged on October 18, 2023. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #5 was admitted on July 24, 2023 and discharged on January 26, 2024. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #6 was admitted on January 15, 2024 and was still active at the time of the inspection. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. Client #7 was admitted on September 1, 2023 and discharged on November 14, 2023. There was no documentation that the facility obtained an informed and voluntary consent for the funding source. The facility confirmed that the insurance was billed for the services. This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Clinical Director reviewed the requirement to obtain a consent to release information prior to releasing information with all clinical staff on 6/19/2024. SUD clinical director reviewed with medical staff that a release of information must be obtained prior to completing a medical prior authorization. SUD Clinical Director is requiring staff to complete all consents by 8/1/2024. SUD Director will complete chart audits to ensure all client charts are updated by 8/5/2024. Director will complete quarterly chart audits to ensure this deficiency does not happen again. |
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.
|
Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of seven client records reviewed. Client #3 was admitted on July 31, 2023 and was discharge on September 13, 2023. There was no documentation that a copy of an informed and voluntary consent to release information form for a legal entity dated July 31, 2023 and release of information form for an emergency contact on August 7, 2023 were offered to the client. These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Clinical Director reviewed the requirement to offer and document that a copy of a client consent was offered to the client and a copy maintained in the client record with all clinical staff on 6/19/2024. SUD Clinical Director is requiring staff to complete all consents by 8/1/2024. SUD Director will complete chart audits to ensure all client charts are updated by 8/5/2024. Director will complete quarterly chart audits to ensure this deficiency does not happen again. |