INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 17, 2021 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 of the Alleghenies 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) (2) 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:
(2) Specific information disclosed.
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Observations
Based on two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed to not exceed Pa. code 255.5 (a)(6) in client records # 6. Also, client # 2 and # 6 has an informed and voluntary consent from the client for the disclosure of information that did not include the specific information disclosed.Client # 2 was admitted on August 11, 2020 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a government agency signed and dated on August 11, 2021 did not provide the specific information to be released. Client # 6 was admitted on November 11, 2020 and was discharged on December 21, 2020. An informed and voluntary consent from the client for the disclosure of information to a government agency signed and dated on November 11, 2021 did not provide the specific information to be released. Also, an informed and voluntary consent from the client for the disclosure of information to an employment service agency signed and dated on November 11, 2020 and an employer signed and dated on November 16, 2020 exceeded Pa code 255.5 (a)(6).These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the annual inspections conducted on September 17, 2020 and May 13-15, 2019.
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Plan of Correction
On July 8, 2021, Program Supervisor will re-educate all staff (during staff meeting) on 709.28 (a)(6) regarding confidentiality and completing the entire release of information to be released to the correct entity (employer, government, and treatment). In addition, staff will also be re-educated on signature requirements for releases of information. Program supervisor will obtain signatures from all staff regarding the confidentiality re-education.
Starting Jul 2021, Program Supervisor will conduct random chart audits to ensure the confidentiality on the release of information is completed accurately and will follow up with individual staff during supervision if needed. |
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 three of three applicable client records reviewed, the facility failed to provide treatment and rehabilitation plans reviewed and updated at least every 60 days in client records # 1, 2, and 3. Client # 1 was admitted on December 3, 2020 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on February 4, 2021. A treatment and rehabilitation plan update was due to occur on April 4, 2021 however, the next documented treatment and rehabilitation plan was developed on May 21, 2021.Client # 2 was admitted on August 11, 2020 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on August 18, 2020. A treatment and rehabilitation plan update was due to occur on October 18, 2020 and December 18, 2020 however, the next documented treatment and rehabilitation plan was developed on January 4, 2021.Client # 3 was admitted on November 4, 2020 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on January 19, 2021. A treatment and rehabilitation plan update was due to occur on March 19, 2021 however, the next documented treatment and rehabilitation plan was developed on May 3, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On July 14, 2021, Program Supervisor will educate all staff (during staff meeting) regarding the requirements to ensure all clients have an active and current treatment plan. Program Supervisor developed a treatment plan tracer in excel which will be in effect as of July 16, 2021 for all staff to review weekly. Program supervisor will have staff sign off on the treatment plan requirements during staff meeting. Program supervisor will be responsible to review treatment plan tracker weekly during supervision with staff. Effective July 16, 2021 for all items to be completed.
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