INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC Mercy 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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710.23(b) LICENSURE Patient Records
§ 710.23. 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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent for the release of client related information in one of seven client records.Client #2 was admitted on December 1, 2022. A consent was signed for the funding source on December 1, 2022; however, the funding source information was incorrect. It was confirmed that information had been sent and payment received by a funding source that was not listed on the signed consent.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A valid insurance company/payer must be documented on a release of information meeting the requirements of 42 CFR Part 2. If the verification of benefits does not align with what is documented on a pre signed release, a new release must be completed, in full, with a new patient signature, new date of signing, and updated name of the insurance company/payer. At the time of the review, a new release was obtained for the patient in question. Upon admission to the program, all consents, including release to insurance company will be reviewed, in-full by the admitting nurse or nurse clinician for accuracy. Prior to utilization review, the care manager assigned to the patient will ensure an appropriate consent is signed prior to review/engagement with payor. |
710.25(a) LICENSURE Notification and Termination
§ 710.25. Notification and termination.
(a) The director shall notify the patient, in writing, of a decision to involuntarily terminate the patient ' s treatment in the service. The notice shall include the reasons for termination.
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Observations
Based on a review of client records, the facility failed to document a written notification of involuntary termination in one of one client records.Client #4 was admitted on July 12, 2022 and involuntarily terminated on July 15, 2022. There was no documentation of a written notification of involuntary termination in client record #4.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All patients involuntarily discharged from the program will receive, in writing, an outline of behaviors which led to the discharge. If patients refuse to sign the form, the discharging nurse will write the refusal on the form, sign, and date, before sending to medical records. Regardless of whether the patient chooses to accept or deny the written notification, there must be clear documentation of an attempt within the client's record. In this specific case, the nurse assigned to the patient has been educated on the expected process and given feedback on how to avoid a deficiency like this in the future. |