INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 6-7, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Safe Harbor Behavioral Health of UPMC Hamot 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) (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
The facility failed to obtain an informed and voluntary consent from the client which included the specific information to be disclosed, in four of eight client records reviewed on March 6-7, 2018. Client records # 1, 2, 8 and 10 did not list the specific information to be released to the third party payor. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. 3/16/18 at 2:30 PM Privacy Officer will be providing training to the financial intake department.
2. 3/16/18 at 12:00 PM Clinical Supervisor will be reviewing with all outpatient staff.
3. 3/15/2018 the AMS Insurance ROI was updated (by Administrative Assistant) to support staff decision making to complete the form for release of information up to only the five allowable areas. Since the forms have been changed, the staff have no choice but to use this modified form.
4. As of March, 2018, this element will be incorporated into the Clinical Supervisor's monthly chart audits, which are part of the quality assurance committee's monthly reporting.
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The facility failed to document written acknowledgement by clients they have the right to appeal a decision limiting access to their records to the director, in eight of eight client records reviewed on March 6-7, 2018.Client records # 1, 2, 3, 4, 7, 8, 9 and 10 did not document the right to appeal. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. On 3/9/18 this statement was added to the "AMS Consent Trtmt Agmt" (Consent for Treatment Agreement): the statement reads, "You have the right to appeal a decision limiting access to your records to the director."
Administrative Assistant made these changes with oversight from Clinical Supervisor. These changes have already been made in the electronic record, so this corrected form is the only option for staff to utilize. The form change was confirmed by the Compliance Officer and Executive Director on 3/15/2018.
2. On 3/16/2018 at 12:00 PM the Clinical Supervisor will review the "Rights" section of the AMS Consent Trtmt Agmt. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
The facility failed to document the type and/or frequency of treatment and rehabilitation services in seven of eight client records reviewed on March 6-7, 2018. Client records # 1, 3, 4, 7, 8 and 10 were missing the type and frequency of services. Client record # 9 was missing the type of services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. By 3/31/2018 the treatment plan form will be updated by the Administrative Assistant to include prompts to direct staff to ensure they are identifying type and frequency more clearly, and including minimum type and frequency. These forms are in the electronic medical record, necessitating staff make these changes. Changes have been overseen by the Clinical Supervisor, Project Director and Compliance Officer.
2. On 3/16/18 at 12:00 P.M. the Clinical Supervisor will provide training to all outpatient/intensive outpatient staff.
3. As of March 2018, the Clinical Supervisor will incorporate a review of these changes into monthly chart audits, which are reported to the Quality Assurance committee. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to update treatment and rehabilitation plans at least every 60 days in three of six client records reviewed on March 6-7, 2018. Client # 1 had an update due by December 13, 2017. The update was completed on January 8, 2018. Client # 7 had an update due by September 14, 2017. There was no documentation provided of an update. Client # 8 had an update due by February 8, 2018. There was no documentation provided of an update. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. On 3/16/2018 Clinical Supervisor will review requirements with all outpatient/intensive outpatient staff to ensure reviews are completed at least every 60 days, even if the individual in services is not present.
2. By 3/31/2018, Administrative Assistant will adjust treatment and rehabilitation plan review forms. The form will include an opportunity to document if the individual in services is present or not, and the staff will complete the review. An existing mechanism exists to auto-notify staff of review dates.
3. As of March 2018, the Clinical Supervisor will monitor this charting element in monthly audits, which are then reported to the Quality Assurance Committee. |