INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20, 2007 to February 22, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on March 23, 2007.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
With the exception of the administrative staff, clinical staff, and one nurse, the remainder of the staff on the unit need to obtain 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.
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Plan of Correction
All Butler Regional Recovery Program staff members will receive DOH approved
training in 6 hours of HIV/Aids and 4
hours of TB/STD/Communicable Disease
training by 12/31/07. On 3/21/07 the
Clinical Supervisor, the Behavioral
Health Clinical Educator and representatives of BMH Education Department met to develop an education plan that addresses this deficiency. |
157.21 (b)(4) LICENSURE Admission - detoxification
157.21 Admission - detoxification.
(b) Admission procedures shall include documentation of the following:
(4) Psychosocial evaluation.
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Observations
The content of the psychosocial evaluations reviewed in the inpatient records were more historical in content than evaluative. The evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the patient's current situation.
Also, the evaluations were not consistent in identifying the client's assets/strengths, support systems, coping/defense mechanisms, negative factors that may affect treatment , and the client's attitude toward treatment.
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Plan of Correction
Butler Regional Recovery Program clinical staff will be educated regarding formulating a comprehensive
composite psychosocial evaluation based
on patient data collected. The Clinical Supervisor and Department Clinical Educator will complete education by April 15, 2007 and will perform ongoing monitors to ensure compliance.
The Initial Admission Assessment will be revised to include prompts which will ensure consistent identification of these areas. Target for completion of revised assessment is 12/31/07.
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157.23 (b) LICENSURE Patient records.
157.22 Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects and coordinating bodies: disclosure of client-oriented information).
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Observations
The "Patient Consent To Treatment" form contains a general consent to release information located in the section Titled 'Consent to Verbal Release To Payor' which states "I hereby authorize Butler Regional Recovery Program/Butler Memorial Hospital to verbally disclose information pertinent to my treatment to any and all payers including the Single County Authority of the county in which I reside". This form was found in all patient records reviewed. General consents to release information violate state and federal law and regulation.
Also, in client record number 3, there was a "Patient Registration" form that contained a general consent to release information. The Medicare Title XVIII Assignment section included the statement "I authorize any holder of medical and information about me to release to Medicare and it's agents any information needed to determine these benefits for related services".
General consents to release information are specifically prohibited at 42 CFR Part 2, Subpart C, Subsection 2.32 and are indirectly prohibited at 42 CFR Part 2, Subpart C, Subsection 2.31 and at 71 P.S. Subsection 1690.108(b) and 28 Pa. Code Subsection 157.23(b) as it refers to 4 Pa. Code subsection 255.5.
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Plan of Correction
The "Patient Consent to Treatment" form will be revised with section
"Consent to Verbal Release to Payor"
deleted. The "Patient Registration"
form Medicare Title XVIII Assignment
section will be revised to meet regulatory requirements. The BRRP
Clinical Supervisor and managers of
the BMH Medical Records and Patient
Registration Departments will be
responsible with a target date for
completion being 1/1/08.
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