INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the October 31 & November 1, 2011 licensure renewal inspection. The follow-up inspection was conducted on May 25, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Ridgeview Adolescent Behavioral Health Center at Pittsburgh 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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the specific information to be disclosed and the purpose of disclosure in eleven of thirteen client records.
The findings included:
Twenty-two client records were reviewed on May 25, 2012. Thirteen client records were reviewed for confidentiality and were required to have an informed and voluntary consent from the client; including the specific information to be disclosed and the purpose of the disclosure. The facility failed to obtain an informed and voluntary consent from the client; including the specific information to be disclosed and/or the purpose of disclosure in client records # 1, 2, 3, 4, 5, 6, 8, 9, 11, 12, and 13.
The finding were reviewed with the facility director, the clinical supervisor, and the lead counselor and were not disputed.
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Plan of Correction
Beginning June 11, 2012, all consents will be completed with informed and voluntary consent from the client; to include the specific information to be disclosed and/or the purpose of the disclosure and will be found in all client open records. Alicia Fairman, VP of Clinical Services will conduct one on one trainings with necessary staff and assist in the implementation of a regular chart audit to ensure full compliance with this regulation. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document when the case consultations were completed in eleven of twenty-two client records.
The findings included:
Twenty-two client records were reviewed on May 25, 2012, and all were required to include documentation of case consultations. The facility policy states case consultations are due within seven days of admission then every 90 days thereafter. The facility did not document when the case consultations were completed in eleven client records, client records # 1, 5, 6, 13, 14, 15, 16, 17, 18, 19, and 21.
The finding was reviewed with the facility director, the clinical supervisor, and the lead counselor and was not disputed.
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Plan of Correction
Beginning July 1, 2012, all case consultations will clearly state a date of completion in the EHRS system which will be entered by the clinician on the date of completion of the consult. Compliance will be monitored during monthly chart audits with lead counselors, Jen Snow and Kim Nagy. |