This report is a result of an on-site licensure renewal inspection conducted on November 8, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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Observations
The facility failed to specifically identify the information to be released to the urinalysis lab and the bloodwork lab in all fourteen client records reviewed. Every urinalysis and bloodwork lab consent to release form, in all the client records, allowed for the release of presence in treatment, medical history and physical, to include medications, diagnosis, prognosis, and progress in treatment, psychosocial data and assessment, discharge summary, aftercare plan, all clinical and medical progress notes and treatment plans, and all correspondence contained in the client's record; however, there was no specific mention of urinalysis or bloodwork related information.
Client #1 was admitted on October 17, 2018 and was an active client at the time of the inspection.
Client #2 was admitted on October 11, 2018 and was an active client at the time of the inspection.
Client #3 was admitted on October 17, 2018 and was an active client at the time of the inspection.
Client #4 was admitted on September 7, 2018 and was discharged October 8, 2018.
Client #5 was admitted on August 13, 2018 and was discharged October 1, 2018.
Client #6 was admitted on August 8, 2018 and was discharged September 7, 2018.
Client #7 was admitted on June 6, 2018 and was discharged July 11, 2018.
Client #8 was admitted on October 9, 2018 and was an active client at the time of the inspection.
Client #9 was admitted on October 2, 2018 and was an active client at the time of the inspection.
Client #10 was admitted on September 7, 2018 and was an active client at the time of the inspection.
Client #11 was admitted on May 5, 2018 and was discharged October 1, 2018.
Client #12 was admitted on May 9, 2018 and was discharged July 7, 2018.
Client #13 was admitted on June 7, 2018 and was discharged October 22, 2018.
Client #14 was admitted on July 7, 2018 and was discharged September 17, 2018.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The program director has reviewed regulations pertaining to release of information, and completed the following corrective action, effective 11/12/2018.
Lab work releases of information were revised in the electronic medical record to limit the amount of information released to the following:
1) Diagnosis - for the purpose of toxicology/urinalysis and for billing
To ensure this deficiency does not recur, the clinical director will conduct monthly chart reviews to ensure that releases of information are appropriately filled out and comply with Department of Drug and Alcohol regulations.
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