INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 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 client 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 seven out of seven records reviewed.Client #1 was admitted on January 11, 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 #2 was admitted on February 12, 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 1, 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 August 30, 2023 and discharged on October 31, 2023. 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 August 23, 2023 and discharged on November 8, 2023. 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 August 11, 2023 and discharged on December 29, 2023. 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 October 24, 2023 and discharged on February 13, 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 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. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in one of seven records reviewed.Client #7 was admitted on October 24, 2023 and discharged on February 13, 2024. The record contained two informed and voluntary consents to release information for a mental health provider and a legal entity that were signed by the client on October 24, 2023 that did not include the purpose of disclosure. This is a repeat citation from the June 8, 2023 licensing inspection.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 with the purpose of the disclosure documented 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 correct 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. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the clients that recorded the date, event, or condition upon which the consent will expire in one out of seven records reviewed.Client #7 was admitted on October 24, 2023 and discharged on February 13, 2024. A release of information form to a mental health provider and a legal entity dated October 24, 2023, did not document when the consents will expire.This is a repeat citation from the June 8, 2023 licensing inspection.This finding wase reviewed with the 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 with the date, event or condition upon the consent will expire 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 correct 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. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client and a copy maintained in the client record in one out of seven client records reviewed. Client #7 was admitted on October 24, 2023 and discharged on February 13, 2024. There were consents for a mental health provider and legal entity that were signed on October 24, 2023. There was no documentation in the record that a copy had been offered.These findings were reviewed with the 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
with documentation on whether the client was offered and whether or not the client accepted a copy of their consent 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 correct 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. |