INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17 & 18, 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:
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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 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 six out of seven records reviewed.
Client #2 was admitted on February 20, 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 March 4, 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 #4 was admitted on September 27, 2023 and discharged on January 11, 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 #5 was admitted on December 27, 2023 and discharged on February 14, 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 December 12, 2023 and discharged on April 30, 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 #7 was admitted on March 5, 2024 and discharged on May 16, 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.
This is a repeat violation from the June 22, 2022 and June 21, 2023 licensing inspections.
This finding was reviewed with facility staff during the licensing process.
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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. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for obtaining a release of information form from the client for the disclosure of information contained in the client record was submitted and approved by the Department for the June 22, 2022 and the June 21, 2023 annual licensing inspections. Obtaining a release of information form from the client for the disclosure of information contained in the client record was again found to be a deficiency in the June 17 & 18, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director and clinical supervisor will ensure all plans of correction are implemented and adhered to. Director and Supervisor will complete monthly chart audits for all clinicians to ensure all plans of correction are being followed. Director and Supervisor updated and finalized a "chart audit sheet" for staff, supervisor and director to use on an ongoing basis. |