INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 18, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Banyan Philadelphia LLC, 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 client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of fourteen client records reviewed.
Client #1 was admitted into the partial hospitalization level of care on October 14, 2021 and was active at the time of inspection. There was documentation of billing to the funding source since the client's admission; however, there was no consent to release information form on file prior to the disclosure of information.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The program director has reviewed regulations pertaining to release of information, and completed the following corrective action, effective 11/24/2021. The staff member who neglected to complete the proper documentation was notified immediately. To ensure this deficiency does no recur, the program director will conduct monthly chart reviews to ensure that releases of information are appropriately filled out and comply with Department of Drug and Alcohol regulations. Regular staff trainings will be conducted on the intake process to ensure the proper documentation is filled out at the time of admission. |
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
Based on a review of client records, the facility failed to document that treatment plans were reviewed and updated at least every 60 days in four of seven applicable client records reviewed.
Client #2 was admitted on August 29, 2021 and was active at the time of inspection. A treatment plan update was completed on September 3, 2021, and the next update was due no later than November 3, 2021. However, the update was not documented as of the date of the inspection.
Client #10 was admitted on August 23, 2021 and was active at the time of inspection. A treatment plan update was completed on August 30, 2021, and the next update was due no later than October 30, 2021. However, the update was not documented as of the date of the inspection.
Client #12 was admitted on April 6, 2021 and was discharged October 14, 2021. The comprehensive treatment plan was completed on April 15, 2021 and the first update was due no later than June 15, 2021. However, the update was not completed as of the date of the inspection.
Client #14 was admitted on December 23, 2020 and was discharged March 22, 2021. The comprehensive treatment plan was completed on January 12, 2021 and the first update was due no later than March 12, 2021. However, the update was not completed as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program director has reviewed regulations pertaining to treatment plan reviews being updated at least every 60 days.
The primary therapist for the identified patients still admitted that were missing treatment plan reviews was notified immediately.
The ensure this deficiency does not recur, the program director will conduct monthly chart audits to ensure that treatment plans are reviewed and updated within the specified time frames.
Regular staff trainings will be conducted on treatment plan review process. |