INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC Western Behavioral Health at Safe Harbor 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) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency or organization to whom the disclosure will be made in one of seven client records.Client #2 was admitted on May 12, 2022 and remains an active client. Client #2 signed a consent to release information on January 5, 2023 which did not include documentation of the recipient of the information to be released.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 1/26/23 Program Manager reviewed the specifics of the citation with staff and provided education to staff on 709.28. Confidentiality.
OP staff will obtain complete releases of information prior to disclosure of client records.
Staff will complete releases in full with patient prior to the client signing the release.
This element will be incorporated into the Program Managers monthly chart audits, which are part of the quality assurance committee's monthly reporting.
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