INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 6, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Greenbriar Treatment Center 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:
|
Plan of Correction
|
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.
|
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 four of fourteen records reviewed.
Client #1 was admitted to the detoxification level of care on February 13, 2023 and discharged on February 17, 2023. The client record had a letter informing a medical provider that the client was admitted to the facility dated February 13, 2023; however, there was not an informed and voluntary consent from the client for the disclosure of information in the client record.
Client #5 was admitted to the detoxification level of care on September 16, 2023 and discharged on September 17, 2022. The client record had a letter informing a medical provider that the client was admitted to the facility dated September 16, 2022; however, there was not an informed and voluntary consent from the client for the disclosure of information in the client record.
Client #8 was admitted to the inpatient level of care on February 17, 2023 and was current at the time of the inspection. The client record had a letter informing a medical provider that the client was admitted to the facility dated February 13, 2023; however, there was not an informed and voluntary consent from the client for the disclosure of information in the client record.
Client #12 was admitted to the inpatient level of care on September 17, 2022 and was discharged on October 3, 2022. The client record had a letter informing a medical provider that the client was admitted to the facility dated September 16, 2022; however, there was not an informed and voluntary consent from the client for the disclosure of information in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Within 30 days (May 5, 2023), the Regional Director of Health Information Management shall complete an internal training on Confidentiality including 42 CFR Part 2. Within the training, a review of the requirement that staff must obtain the informed and voluntary consent (Release of Information) from the patient for the disclosure of information. Proof of training shall be retained in the employee files. Post-training, the Health Information Management Department will audit Release of Information forms weekly for 3 months to ensure compliance is maintained then monthly thereafter. The auditing process shall be ongoing by the Health Information Management Department. Audit results are forwarded to the Program Director for review. |
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.
|
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 specific information disclosed in one of fourteen records reviewed.
Client #10 was admitted to the inpatient level of care on February 11, 2023 and was current at the time of the inspection. An informed and voluntary consent form to a government official was signed and dated by the client on February 13, 2023, that did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Within 30 days, May 5, 2023, the Regional Director of Health Information Management shall complete an internal training on Confidentiality including 42 CFR Part 2. Within the training, a review of completing the Release of Information shall be completed to include the type of information to be released. Proof of training shall be retained in the employee files. Post-training, the Health Information Management Department will audit Release of Information forms weekly for 3 months to ensure compliance is maintained then monthly thereafter. The auditing process shall be ongoing by the Health Information Management Department. Audit results are forwarded to the Program Director for review.
|