INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 31, 2023 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of two applicable client records reviewed.
Client #4 was admitted to the partial hospitalization activity on August 20, 2023 and was administratively discharged on September 11, 2023. There was no documentation, in the record, indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
It was discovered that the proper documentation was not available in Banyan Philadelphia EMR to use when a patient is being administratively discharged from programming. The Health Information team was notified and on 10/31/2023, the proper documentation was made live in Banyan Philadelphia EMR. To ensure that the deficiency does not recur, the Therapists and Case Managers were trained on the new document and informed that it needed to be used during cases where patients are administratively discharged from the program. The training occurred during the Treatment Team Meeting on 11/8/2023. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to notify the client of the opportunity to request reconsideration of a decision terminating treatment in one of one applicable client records reviewed.
Client #11 was admitted to the outpatient activity on October 2, 2023 and was administratively discharged on October 17, 2023. The termination letter, dated October 19, 2023, failed to notify the client of the opportunity to request reconsideration of the decision terminating treatment and there was no other documentation, in the record, indicating notification.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
It was discovered that the proper documentation was not available in Banyan Philadelphia EMR to use when a patient is being administratively discharged from programming. The Health Information team was notified and on 10/31/2023, the proper documentation was made live in Banyan Philadelphia EMR. To ensure that the deficiency does not recur, the Therapists and Case Managers were trained on the new document and informed that it needed to be used during cases where patients are administratively discharged from the program. The training occurred during the Treatment Team Meeting on 11/8/2023. |