INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 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, 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 obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in two of fourteen client records reviewed.
Client #2 was admitted to the partial hospitalization activity on January 3, 2024 and was discharged on February 5, 2024. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #9 was admitted to the outpatient activity on February 5, 2024 and was discharged on March 7, 2024. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In January 2024, there was a transition from one billing company to another one. The consent form for releasing information was revised to specify the entity and the exact details of information that can be disclosed. This revision was implemented in January 2024, ensuring that all patients admitted after this date are in compliance. The Intake Coordinator also received retraining on the revised form in January 2024. The Clinical Director will ensure the corrective action plan is implemented through ongoing chart audits. |
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 document the purpose of the disclosure on consent to release information forms in five of fourteen client records reviewed.
Client #4 was admitted to the partial hospitalization activity on July 10, 2024 and was discharged on July 23, 2024. There were release of information forms to two medical service providers, a behavioral health provider, and a pharmacy that were all signed and dated by the client on July 10, 2024; however, the purpose of the disclosure was not documented on any of the consent forms.
Client #5 was admitted to the partial hospitalization activity on June 21, 2024 and was discharged on June 24, 2024. There were release of information forms to two medical service providers and a behavioral health provider that were all signed and dated by the client on June 21, 2024; however, the purpose of the disclosure was not documented on any of the consent forms.
Client #6 was admitted to the partial hospitalization activity on September 19, 2024 and was active at the time of the inspection. There were release of information forms to two medical service providers, a behavioral health provider, and a pharmacy that were all signed and dated by the client on September 19, 2024; however, the purpose of the disclosure was not documented on any of the consent forms.
Client #7 was admitted to the partial hospitalization activity on September 23, 2024 and was active at the time of the inspection. There were release of information forms to a medical service provider and a behavioral health provider that were signed and dated by the client on September 23, 2024; however, the purpose of the disclosure was not documented on both consent forms.
Client #13 was admitted to the outpatient activity on October 3, 2024 and was active at the time of the inspection. There were release of information forms to two medical service providers and a behavioral health provider that were all signed and dated by the client on October 3, 2024; however, the purpose of the disclosure was not documented on any of the consent forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director retrained staff on 10/18/24 on filling out consent forms in their entirety including "purpose for disclosure" checkboxes. The Clinical Director emailed Health Information on 10/28/24 to request that consents be populated with appropriate checkboxes for purpose of disclosure already marked off to reduce the incidence of human error when completing consent forms. The Clinical Director will be responsible for ensuring the plan is implemented through ongoing chart audits. |