INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2021 through December 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, the Hospital of the University of Pennsylvania 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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711.61(c)(6) LICENSURE Psychosocial Evaluation
711.61. Intake and admission.
(c) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document, as part of their intake and admission process, a psychosocial evaluation of the client in seven of seven applicable client records reviewed.
Client #1 was admitted into the non-hospital detoxification activity on December 11, 2021 and was still active at the time of the inspection.
Client #2 was admitted into the non-hospital detoxification activity on December 13, 2021 and was still active at the time of the inspection.
Client #3 was admitted into the non-hospital detoxification activity on July 16, 2021 and was discharged on July 20, 2021.
Client #4 was admitted into the non-hospital detoxification activity on June 8, 2021 and was discharged on June 11, 2021.
Client #5 was admitted into the non-hospital detoxification activity on September 10, 2021 and was discharged on September 15, 2021.
Client #6 was admitted into the non-hospital detoxification activity on November 28, 2021 and was discharged on December 1, 2021.
Client #7 was admitted into the non-hospital detoxification activity on August 30, 2021 and was discharged on September 4, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Policy # BH-21-10 Admission and Intake requires a biopsychosocial evaluation to be completed within twenty-four (24) hours of an individual's admission to the Inpatient Detoxification Unit. The patient's assigned addictions counselor is responsible for completing the biopsychosocial evaluation.
Addiction counselors will be provided education on Policy # BH-21-10 by 1/7/2022.
Education will be provided by Nursing Director and Nursing Unit Manager
Record of policy training will be maintained in employee record
Beginning January 10, 2022, Addiction Counselors will conduct chart audits for completion of biopsychosocial evaluation as assigned by Nursing Unit Manager. Ten percent (10%) of open charts or 20 charts/month, whichever is greater, will be audited by each Addiction Counselor for biopsychosocial completion consistent with regulatory standard and to be continued until three months of sustained compliance is achieved.
Results of open patient record audits will be shared with Addiction Counselor team and Department leadership. Nursing Clinical Director or his designee will report results of compliance audits to the HUP Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight. The Nursing Clinical Director will evaluate the results and implement any further process changes and audits, as needed.
All clients noted in the findings have been discharged and the clients' medical records cannot be updated. However, staff will be retrained and procedures are being put into place as outlined above for future documentation compliance. Education will be completed by 1/7/2022.
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711.62(a)(6) LICENSURE Follow-up Information
711.62. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(6) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in five of five applicable client records reviewed.
Client #3 was admitted into the non-hospital detoxification activity on July 16, 2021 and was discharged on July 20, 2021. There was no follow-up information documented in the record as of the date of the inspection.
Client #4 was admitted into the non-hospital detoxification activity on June 8, 2021 and was discharged on June 11, 2021. There was no follow-up information documented in the record as of the date of the inspection.
Client #5 was admitted into the non-hospital detoxification activity on September 10, 2021 and was discharged on September 15, 2021. There was no follow-up information documented in the record as of the date of the inspection.
Client #6 was admitted into the non-hospital detoxification activity on November 28, 2021 and was discharged on December 1, 2021. There was no follow-up information documented in the record as of the date of the inspection.
Client #7 was admitted into the non-hospital detoxification activity on August 30, 2021 and was discharged on September 4, 2021. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction:
Policy # BH-21-04 Post-Discharge Follow Up outlines to the procedure for follow up once an individual is discharged from the Inpatient Detoxification Unit. Currently, the policy provides for Inpatient Detoxification Unit staff to contact the individual's aftercare provider within seven (7) days of their discharge from the Inpatient unit. This policy was amended on 12/22/2021 to include post-discharge follow up with the individual if they have not complied with their aftercare appointment.
Revised policy will be reviewed with staff conducting post-discharge follow-up phone calls by 1/7/2022
Education will be provided by Nursing Director and Nursing Unit Manager
Record of policy training will be maintained in employee record
Beginning January 10, 2022, Nursing Unit Manager or designee will conduct chart audits for adherence to standard. Ten percent (10%) of open charts or 20 charts/month, whichever is greater, will be audited for documentation of post-discharge follow-up phone calls and to be continued until three (3) months of sustained compliance is achieved.
Results of patient record audits will be provided to department staff by the Nurse Manager. Nursing Clinical Director or his designee will report results of compliance audits to the HUP Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight. The Nursing Clinical Director will evaluate the results and implement any further process changes and audits, as needed.
All clients noted in the findings have been discharged and the clients' medical records cannot be updated. However, staff will be retrained and procedures are being put into place as outlined above for future documentation compliance. Education will be completed by 1/7/2022.
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711.62(c)(2) LICENSURE Informed & Voluntary Consent
711.62. Client records.
(c) Confidentiality.
(2) 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 complete an informed and voluntary consent to release information form prior to the disclosure of information in seven of seven applicable client records reviewed.
Client #1 was admitted into the non-hospital detoxification activity on December 11, 2021 and was still active at the time of the inspection. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
Client #2 was admitted into the non-hospital detoxification activity on December 13, 2021 and was still active at the time of the inspection. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
Client #3 was admitted into the non-hospital detoxification activity on July 16, 2021 and was discharged on July 20, 2021. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
Client #4 was admitted into the non-hospital detoxification activity on June 8, 2021 and was discharged on June 11, 2021. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
Client #5 was admitted into the non-hospital detoxification activity on September 10, 2021 and was discharged on September 15, 2021. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
Client #6 was admitted into the non-hospital detoxification activity on November 28, 2021 and was discharged on December 1, 2021. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
Client #7 was admitted into the non-hospital detoxification activity on August 30, 2021 and was discharged on September 4, 2021. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction:
Policy BH-21-09 Emergency Contact Notification for Individuals Leaving Treatment Against Medical Advice requires Inpatient Detoxification staff to confirm the name and contact information for an individual's designated emergency contact. Individuals are also asked to sign an Addiction Services Consent for Release of Information for the contact person. Refusals to sign a Consent are documented in the individual's medical record.
Policy BH-21-11 Confidentiality of Patient Records was revised on 12/22/2021 to reflect that a Consent form is required for an individual's funding source supporting their admission to the Inpatient Detoxification Unit.
Department staff will be provided education on Policies BH-21-09 and BH-21-11 and obtaining consent for release of information on the appropriate documentation methods, including the electronic medical record document "Consent for the Release of Substance Use Disorder Treatment Records" by 1/7/2022
Education will be provided by Nursing Director and Nursing Unit Manager
Record of education training will be maintained in employee record
Beginning January 10, 2022, Nursing Unit Manager or designee will conduct chart audits for adherence to standard. Ten percent (10%) of open charts or 20 charts/month, whichever is greater, will be audited for consent to release information compliance and to be continued until three (3) months of sustained compliance is achieved.
Results of open patient record audits will be provided to department staff by the Nursing Unit Manager. Nursing Clinical Director or his designee will report results of compliance audits to the HUP Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight. The Nursing Clinical Director will evaluate the results and implement any further process changes and audits, as needed.
Staff will be retrained as outlined above by 1/7/2022 for future compliance.
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711.62(c)(2)(i) LICENSURE Name of Person/agency/organization
711.62. Client records.
(c) Confidentiality.
(2) 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:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made to on a consent to release information form in one of seven applicable client records reviewed.
Client #7 was admitted into the non-hospital detoxification activity on August 30, 2021 and was discharged on September 4, 2021. There was a release of information form, signed and dated by the client on August 30, 2021 that did not document the name of the person, agency or organization to whom the disclosure would be made to.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction:
Policy BH-21-11 Confidentiality of Patient Records were revised on 12/22/2021 to reflect that the name of the person, agency or organization to whom the individual is consenting the release of information must be noted on the Addiction Services Consent for Release of Information form.
Department staff will be provided education on Policies BH-21-09 and BH-21-11 and obtaining consent for release of information on the appropriate documentation methods, including the electronic medical record document "Consent for the Release of Substance Use Disorder Treatment Records," with emphasis on including the name of the person, agency or organization to whom disclosure is made by 1/7/2022
Education will be provided by Nursing Director and Nursing Unit Manager
Record of education training will be maintained in employee record
Beginning January 10, 2022, Nursing Unit Manager or designee will conduct chart audits for adherence to standard. Ten percent (10%) of open charts or 20 charts/month, whichever is greater, will be audited for consent to release information compliance to be continued until three (3) months of sustained compliance is achieved.
Results of open patient record audits will be provided to department staff by the Nursing Unit Manager by. Nursing Clinical Director or his designee will report results of compliance audits to the HUP Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight. The Nursing Clinical Director will evaluate the results and implement any further process changes and audits, as needed.
Client # 7 noted in the findings has been discharged and the client's medical record cannot be updated. However, staff will be retrained and procedures are being put into place as outlined above for future documentation compliance. Education will be completed by 1/7/2022.
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711.62(c)(2)(iii) LICENSURE Purpose of Disclosure
711.62. Client records.
(c) Confidentiality.
(2) 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:
(iii) The 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 a consent to release information form in one of seven applicable client records reviewed.
Client #6 was admitted into the non-hospital detoxification activity on November 28, 2021 and was discharged on December 1, 2021. There was a release of information form to another treatment provider, signed and dated by the client on November 28, 2021 that did not document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction:
Policy # BH-21-11 Confidentiality of Patient Records requires that Consent forms specify the purpose of the disclosure of drug and alcohol treatment information.
Department staff will be provided education on Policies BH-21-09 and BH-21-11 and obtaining consent for release of information on the appropriate documentation methods, including the electronic medical record document "Consent for the Release of Substance Use Disorder Treatment Records," with emphasis on including the purpose of the disclosure by 1/7/2022
Education will be provided by Nursing Director and Nursing Unit Manager
Record of education training will be maintained in employee record
Beginning January 10, 2022, Nursing Unit Manager or designee will conduct chart audits for adherence to standard. Ten (10%) of open charts or 20 charts/month, whichever is greater, will be audited for consent to release information compliance to be continued until three (3) months of sustained compliance is achieved.
Results of open patient record audits will be provided to department staff by Nursing Unit Manager. Nursing Clinical Director or his designee will report results of compliance audits to the HUP Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight. The Nursing Clinical Director will evaluate the results and implement any further process changes and audits, as needed.
Client # 6 noted in the findings was discharged on 12/1/2021 therefore the client's medical record cannot be updated. However, staff will be retrained and procedures are being put into place as outlined above for future documentation compliance. Education will be completed by 1/7/2022.
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711.62(c)(3) LICENSURE Client's copy of consent
711.62. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent to release information form was offered to the client in three of seven applicable client records reviewed.
Client #5 was admitted into the non-hospital detoxification activity on September 10, 2021 and was discharged on September 15, 2021. There was a release of information form to another treatment provider, signed and dated by the client on September 11, 2021; however, there was no documentation, in the record, that a copy of the consent form was offered to the client.
Client #6 was admitted into the non-hospital detoxification activity on November 28, 2021 and was discharged on December 1, 2021. There was a release of information form to another treatment provider, signed and dated by the client on November 28, 2021; however, there was no documentation, in the record, that a copy of the consent form was offered to the client.
Client #7 was admitted into the non-hospital detoxification activity on August 30, 2021 and was discharged on September 4, 2021. There was a release of information form, signed and dated by the client on September 11, 2021; however, there was no documentation, in the record, that a copy of the consent form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction:
Policy # BH-21-11 Confidentiality of Patient Records requires that Consent forms specify the purpose of the disclosure of drug and alcohol treatment information.
Department staff will be provided education on Policies BH-21-09 and BH-21-11 and obtaining consent for release of information on the appropriate documentation methods, including the electronic medical record document "Consent for the Release of Substance Use Disorder Treatment Records," with emphasis on offering a copy of the consent to the patient and that a copy of the consent be maintained in the patient record by 1/7/2022
Education will be provided by Nursing Director and Nursing Unit Manager
Record of education training will be maintained in employee record
Beginning January 10, 2022, Nursing Unit Manager or designee will conduct chart audits for adherence to standard. Ten percent (10%) of open charts or 20 charts/month, whichever is greater, will be audited for consent to release information compliance to be continued until three months of sustained compliance is achieved.
Results of open patient record audits will be provided to department staff by Nursing Unit Manager. Nursing Clinical Director or his designee will report results of compliance audits to the HUP Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight. The Nursing Clinical Director will evaluate the results and implement any further process changes and audits, as needed.
Clients # 5, 6, and 7 noted in the findings have been discharged and the clients' medical records cannot be updated. However, staff will be retrained and procedures are being put into place as outlined above for future documentation compliance. Education will be completed by 1/7/2022.
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710.21(b)(1)(ii) LICENSURE Admission - detoxification
§ 710.21. Admission-detoxification.
(b) Admission procedures shall include documentation of the following:
(1) Histories, which include the following:
(ii) Drug or alcohol history, or both
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Observations
Based on a review of patient records, the facility failed to document, as part of their admission process, a drug and/or alcohol history of the client in three of six applicable patient records reviewed.
Patient #8 was admitted into the hospital detoxification activity on December 11, 2021 and was still active at the time of the inspection. There was no documentation that a drug and/or alcohol history of the client was completed as of the date of the inspection.
Patient #10 was admitted into the hospital detoxification activity on August 13, 2021 and was discharged on August 14, 2021. There was no documentation that a drug and/or alcohol history of the client was completed as of the date of the inspection.
Patient #11 was admitted into the hospital detoxification activity on July 23, 2021 and was discharged on July 27, 2021. There was no documentation that a drug and/or alcohol history of the client was completed as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction:
Policy # BH-21-10 Admission and Intake requires a physician recommendation and/or ASAM Level of Care assessment and a biopsychosocial evaluation for admission to the Inpatient Detoxification Unit. Collectively, the physician evaluation, ASAM Level of Care Assessment and the biopsychosocial evaluation document the individual's drug and alcohol use history.
Because the physician admission documentation did not include a comprehensive drug and alcohol use history, physician staff will be provided education on Admission Documentation requirement including documentation of drug or alcohol history, or both, by 1/7/2022
Education will be provided by Facility Director
Record of education training will be maintained by Facility Director
Beginning January 10, 2022, Facility Director or designee will conduct chart audits for adherence to standard. Ten percent (10%) of open charts or 20 charts/month, whichever is greater, will be audited for completion of drug or alcohol history in admission documentation to be continued until three months of sustained compliance is achieved.
Results of open patient record audits will be provided to physician staff by Facility Director. Facility Director or his designee will report results of compliance audits to the HUP Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight. The Facility Director will evaluate the results and implement any further process changes and audits, as needed.
Records noted in findings are discharged patients and cannot be updated; however, the physician staff will be educated by 1/7/2022 for future documentation compliance. Completion of the training will be maintained by Facility Director.
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710.21(b)(4) LICENSURE Admission - Detoxification
§ 710.21. Admission-detoxification.
(b) Admission procedures shall include documentation of the following:
(4) Psychosocial evaluation.
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Observations
Based on a review of patient records, the facility failed to document, as part of their admission process, a psychosocial evaluation of the patient in six of six applicable patient records reviewed.
Patient #8 was admitted into the hospital detoxification activity on December 11, 2021 and was still active at the time of the inspection.
Patient #9 was admitted into the hospital detoxification activity on November 4, 2021 and was discharged on November 9, 2021.
Patient #10 was admitted into the hospital detoxification activity on August 13, 2021 and was discharged on August 14, 2021.
Patient #11 was admitted into the hospital detoxification activity on July 23, 2021 and was discharged on July 27, 2021.
Patient #12 was admitted into the hospital detoxification activity on April 12, 2021 and was discharged on April 17, 2021.
Patient #13 was admitted into the hospital detoxification activity on October 4, 2021 and was discharged on October 8, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction:
Policy # BH-21-10 Admission and Intake requires a biopsychosocial evaluation to be completed within twenty-four (24) hours of an individual's admission to the Inpatient Detoxification Unit. The patient's assigned addictions counselor is responsible for completing the biopsychosocial evaluation.
Addiction counselors will be provided education on Policy # BH-21-10 by 1/7/2022.
Education will be provided by Nursing Director and Nursing Unit Manager
Record of policy training will be maintained in employee record
Beginning January 10, 2022, Addiction Counselors will conduct chart audits as assigned by Nursing Unit Manager for completion of biopsychosocial evaluation. Ten percent (10%) of open charts or 20 charts/month, whichever is greater, will be audited for biopsychosocial completion to be continued until three (3) months of sustained compliance is achieved.
Results of open patient record audits will be shared with Addiction Counselor team and Department leadership by Nursing Unit Manager. Nursing Clinical Director or his designee will report results of compliance audits to the HUP Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight. The Nursing Clinical Director will evaluate the results and implement any
All clients noted in the findings have been discharged and the clients' medical records cannot be updated. However, staff will be retrained and procedures are being put into place as outlined above for future documentation compliance. Education will be completed by 1/7/2022.
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710.23(a) LICENSURE Patient Records
§ 710.23. Patient records.
(a) In addition to the requirements contained in § 115.32 (relating to contents), the patient ' s medical record shall contain a drug and alcohol support plan, follow-up information, and an aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to document follow-up information in five of five applicable patient records reviewed. Additionally, the facility failed to document a D&A support plan in one of six applicable patient records reviewed.
Patient #9 was admitted into the hospital detoxification activity on November 4, 2021 and was discharged on November 9, 2021. There was no follow-up information documented in the record as of the date of the inspection.
Patient #10 was admitted into the hospital detoxification activity on August 13, 2021 and was discharged on August 14, 2021. There was no follow-up information documented in the record as of the date of the inspection.
Patient #11 was admitted into the hospital detoxification activity on July 23, 2021 and was discharged on July 27, 2021. There was no follow-up information documented in the record as of the date of the inspection.
Patient #12 was admitted into the hospital detoxification activity on April 12, 2021 and was discharged on April 17, 2021. There was no follow-up information documented in the record as of the date of the inspection. Additionally, the record did not contain a drug and alcohol support plan as of the date of the inspection.
Patient #13 was admitted into the hospital detoxification activity on October 4, 2021 and was discharged on October 8, 2021. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction FOLLOW UP INFORMATION AND AFTERCARE PLAN:
Policy # BH-21-04 Post-Discharge Follow Up outlines to the procedure for follow up once an individual is discharged from the Inpatient Detoxification Unit. Currently, the policy provides for Inpatient Detoxification Unit staff to contact the individual's aftercare provider within seven (7) days of their discharge from the Inpatient unit. This policy was amended on 12/22/2021 to include post-discharge follow up with the individual if they have not complied with their aftercare appointment
Revised policy will be reviewed with staff conducting post-discharge follow-up phone calls by 1/7/2022
Education will be provided by Nursing Director and Nursing Unit Manager
Record of policy training will be maintained in employee record
Beginning January 10, 2022, Nursing Unit Manager or designee will conduct chart audits for adherence to standard. Ten percent (10%) of open charts or 20 charts/month, whichever is greater, will be audited for documentation of post-discharge follow-up phone calls to be continued until three (3) months of sustained compliance is achieved.
Results of patient record audits will be provided to department staff by Nursing Unit Manager. Nursing Clinical Director or his designee will report results of compliance audits to the HUP Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight. The Nursing Clinical Director will evaluate the results and implement any further process changes and audits, as needed
All clients noted in the findings have been discharged and the clients' medical records cannot be updated. However, staff will be retrained and procedures are being put into place as outlined above for future documentation compliance. Education will be completed by 1/7/2022.
Plan of correction DRUG AND ALCOHOL SUPPORT PLAN:
Policy # BH-01-05 Multidisciplinary Treatment Plan in the Behavioral Health Patient outlines to the procedure that treatment plans will include, but not be limited to plans to address patient strengths and barriers, treatment goals (short term and long term) that are measurable and attainable, and contain evidence of patient involvement. The support plan is designed to help patients gain a better understanding of chemical dependency and identify formal treatment and supportive activities with the goal of promoting continued sobriety and recovery.
Policy will be reviewed with staff completing behavioral health treatment plans by 1/21/2022
Education will be provided by Nursing Director and Nursing Unit Manager
Record of policy training will be maintained in employee record
Beginning January 24, 2022, Nursing Unit Manager or designee will conduct chart audits for adherence to standard. Ten percent (10%) of open charts or 20 charts/month, whichever is greater, will be audited for documentation of a drug and alcohol support plan to be continued until three (3) months of sustained compliance is achieved.
Results of patient record audits will be provided to department staff by Nursing Unit Manager. Nursing Clinical Director or his designee will report results of compliance audits to the HUP Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight. The Nursing Clinical Director will evaluate the results and implement any further process changes and audits, as needed.
All clients noted in the findings have been discharged and the clients' medical records cannot be updated. However, staff will be retrained and procedures are being put into place as outlined above for future documentation compliance. Education will be completed by 1/21/2022.
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710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of patient records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in six of six applicable patient records reviewed.
Patient #8 was admitted into the hospital detoxification activity on December 11, 2021 and was still active at the time of the inspection. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
Patient #9 was admitted into the hospital detoxification activity on November 4, 2021 and was discharged on November 9, 2021. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
Patient #10 was admitted into the hospital detoxification activity on August 13, 2021 and was discharged on August 14, 2021. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
Patient #11 was admitted into the hospital detoxification activity on July 23, 2021 and was discharged on July 27, 2021. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
Patient #12 was admitted into the hospital detoxification activity on April 12, 2021 and was discharged on April 17, 2021. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
Patient #13 was admitted into the hospital detoxification activity on October 4, 2021 and was discharged on October 8, 2021. There was evidence 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 any of the disclosures. Additionally, there was no client-signed release of information form to the client ' s emergency contact, per Act 41 of 2021 71 P.S. 613.1(8.1), documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction:
Policy BH-21-09 Emergency Contact Notification for Individuals Leaving Treatment Against Medical Advice requires Inpatient Detoxification staff to confirm the name and contact information for an individual's designated emergency contact and to request a signed release of information form for that individual.
Policy BH-21-11 Confidentiality of Patient Records was revised on 12/22/2021 to reflect that a signed consent for release on information is required for an individual's funding source supporting their admission to the Inpatient Detoxification Unit.
Department staff will be provided education on Policies BH-21-09 and BH-21-11 and obtaining consent for release of information on the appropriate documentation methods, including the electronic medical record document "Consent for the Release of Substance Use Disorder Treatment Records" by 1/7/2022
Education will be provided by Nursing Director and Nursing Unit Manager
Record of education training will be maintained in employee record
Beginning January 10, 2022, Nursing Unit Manager or designee will conduct chart audits for adherence to standard. Ten percent (10%) of open charts or 20 charts/month, whichever is greater, will be audited for consent to release information compliance to be continued until three months of sustained compliance is achieved.
Results of open patient record audits will be provided to department staff by the Nursing Unit Manager. Nursing Clinical Director or his designee will report results of compliance audits to the HUP Clinical Effectiveness and Quality Improvement (CEQI) Committee for ongoing quality assurance and performance improvement (QAPI) oversight. The Nursing Clinical Director will evaluate the results and implement any further process changes and audits, as needed.
All clients noted in the findings have been discharged and the clients' medical records cannot be updated. However, staff will be retrained and procedures are being put into place as outlined above for future documentation compliance. Education will be completed by 1/7/2022.
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