INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The facility failed to ensure that all staff persons received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in 1 of 4 applicable personnel records reviewed.
Employee #4 was hired as a counselor on October 21, 2019 and was due to have the communicable disease trainings no later than October 21, 2020. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The program director has reviewed regulations pertaining to communicable disease trainings.
A training has been scheduled for November 11, 2020. Employee #4 is scheduled to attend said training. All new staff members hired since the last training was held in May 2020 are also scheduled to attend.
To ensure this deficiency does not recur, the program director will coordinate with the office manager to confirm that these trainings will be held on site two times per year. Office manager will conduct monthly audits of personnel records to ensure that all staff have required trainings. |
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.
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Observations
The project failed to obtain an informed and voluntary consent to release information form from the client for the disclosure of information contained in the client record in one of fourteen client records reviewed.
Client #5 was admitted on April 10, 2020 and was discharged on May 1, 2020. There was contact between facility staff and the client's family member on September 17, 2020; however, there was no consent form for this family member in the client record prior to the disclosure of information.
These findings were reviewed with program staff during the licensing process.
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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 10/19/2020.
The staff member who entered the the family contact note was notified of the error immediately.
To ensure this deficiency does not recur, the program director will conduct monthly chart reviews to ensure that releases of information for family are entered into the patient record if there is contact with that family member. Program Director will conduct staff training on HIPPA/Confidentiality. |
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.
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Observations
The project failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of fourteen client records reviewed.
Client # 12 was admitted on March 13, 2020 and was discharged on May 13, 2020. A release of information form to the client's employer signed and dated by the client on March 17, 2020, which allowed for the release of a brief description of progress in treatment, prognosis of patient and nature of project (level of care), all of which exceeds the limits established by 4 Pa. Code 255.5.
Client #13 was admitted on July 18, 2020 and was discharged on September 11, 2020. A release of information form to a governmental agency and dated by the client on July 29, 2020, which allowed for the release of Medical history and physical including medications, psychosocial data and assessments, discharge summary, aftercare plan, clinical and medical progress notes, all correspondence contained in record, all of which exceeds the limits established by 4 Pa. Code 255.5.
These findings were reviewed with program staff during the licensing process.
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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 10/21/2020.
Training was completed with all staff to review Pa Code 255.5 and specifically review the charts that had deficiencies.
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. Regular staff trainings will be conducted on Pa Code 255.5 as well. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The project failed to include the purpose of disclosure on informed and voluntary consent to release information forms in fourteen of fourteen client records reviewed.
Client #1 was admitted on September 30, 2020 and was a current client at the time of the inspection. A release of information form to a hospital, signed and dated by the client on September 30, 2020, did not document the purpose of disclosure.
Client #2 was admitted on September 4, 2020 and was a current client at the time of the inspection. A release of information form to a hospital, signed and dated by the client on September 4, 2020, did not document the purpose of disclosure.
Client #3 was admitted on September 23, 2020 and was a current client at the time of the inspection. A release of information form to a hospital, signed and dated by the client on September 24, 2020, did not document the purpose of disclosure.
Client #4 was admitted on May 9, 2020 and was discharged on June 4, 2020. A release of information form to a hospital, signed and dated by the client on May 11, 2020, did not document the purpose of disclosure.
Client #5 was admitted on April 10, 2020 and was discharged on May 1, 2020. A release of information form to a hospital, signed and dated by the client on April 10, 2020, did not document the purpose of disclosure.
Client #6 was admitted on September 14, 2020 and was discharged on October 9, 2020. A release of information form to a hospital, signed and dated by the client on September 14, 2020, did not document the purpose of disclosure.
Client #7 was admitted on September 3, 2020 and was discharged on October 2, 2020. A release of information form to a hospital, signed and dated by the client on September 3, 2020, did not document the purpose of disclosure.
Client #8 was admitted on August 18, 2020 and was a current client at the time of the inspection. A release of information form to a hospital, signed and dated by the client on August 18, 2020, did not document the purpose of disclosure.
Client #9 was admitted on July 29, 2020 and was a current client at the time of the inspection. A release of information form to a hospital, signed and dated by the client on July 29, 2020, did not document the purpose of disclosure.
Client #10 was admitted on June 5, 2020 and was a current client at the time of the inspection. A release of information form to a hospital, signed and dated by the client on June 5, 2020, did not document the purpose of disclosure.
Client #11 was admitted on April 23, 2020 and was discharged on June 8, 2020. A release of information form to a hospital, signed and dated by the client on April 24, 2020, did not document the purpose of disclosure.
Client #12 was admitted on March 13, 2020 and was discharged on May 13, 2020. A release of information form to a hospital, signed and dated by the client on March 13, 2020, did not document the purpose of disclosure.
Client #13 was admitted on July 18, 2020 and was discharged on September 11, 2020. A release of information form to a hospital, signed and dated by the client on July 21, 2020, did not document the purpose of disclosure.
Client #14 was admitted on June 13, 2020 and was discharged on August 13, 2020. A release of information form to a hospital, signed and dated by the client on June 13, 2020, did not document the purpose of disclosure.
These findings were reviewed with program staff during the licensing process.
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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 10/19/2020.
Hospital releases of information were revised in the electronic medical record to include a purpose of disclosure which states:
1)Medical Services
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.
All current patients will sign new consents effective 11/2/2020 to ensure that active patient records are in compliance. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
The project failed to include the dated signature of a witness on informed and voluntary consent to release information forms in fourteen of fourteen client records reviewed.
Client #1 was admitted on September 30, 2020 and was a current client at the time of the inspection. Three release of information forms documented in the client record, all signed and dated on September 30, 2020, did not have a dated witness signature.
Client #2 was admitted on September 4, 2020 and was a current client at the time of the inspection. Three release of information forms documented in the client record, all signed and dated on September 4, 2020, did not have a dated witness signature.
Client #3 was admitted on September 23, 2020 and was a current client at the time of the inspection. Three release of information forms documented in the client record, all signed and dated on September 24, 2020, did not have a dated witness signature.
Client #4 was admitted on May 9, 2020 and was discharged on June 4, 2020. Three release of information forms documented in the client record, all signed and dated on May 11, 2020, did not have a dated witness signature.
Client #5 was admitted on April 10, 2020 and was discharged on May 1, 2020. Two release of information forms documented in the client record, all signed and dated on April 10, 2020, did not have a dated witness signature.
Client #6 was admitted on September 14, 2020 and was discharged on October 9, 2020. Three release of information forms documented in the client record, all signed and dated on September 14, 2020, did not have a dated witness signature.
Client #7 was admitted on September 3, 2020 and was discharged on October 2, 2020. Three release of information forms documented in the client record, all signed and dated on September 3, 2020, did not have a dated witness signature.
Client #8 was admitted on August 18, 2020 and was a current client at the time of the inspection. Two release of information forms documented in the client record, all signed and dated on August 18, 2020, did not have a dated witness signature.
Client #9 was admitted on July 29, 2020 and was a current client at the time of the inspection. Three release of information forms documented in the client record, all signed and dated on July 29, 2020, did not have a dated witness signature.
Client #10 was admitted on June 5, 2020 and was a current client at the time of the inspection. Three release of information forms documented in the client record, all signed and dated on June 5, 2020, did not have a dated witness signature.
Client #11 was admitted on April 23, 2020 and was discharged on June 8, 2020. Three release of information forms documented in the client record, all signed and dated on April 24, 2020, did not have a dated witness signature.
Client #12 was admitted on March 13, 2020 and was discharged on May 13, 2020. Two release of information forms documented in the client record, all signed and dated on March 13, 2020, did not have a dated witness signature.
Client #13 was admitted on July 18, 2020 and was discharged on September 11, 2020. Three release of information forms documented in the client record, all signed and dated on July 21, 2020, did not have a dated witness signature.
Client #14 was admitted on June 13, 2020 and was discharged on August 13, 2020. Three release of information forms documented in the client record, all signed and dated on June 13, 2020, did not have a dated witness signature.
These findings were reviewed with program staff during the licensing process.
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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 10/19/2020.
Lab work releases of information were revised in the electronic medical record to include a dated witness signature.
To ensure this deficiency does not recur, the program 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.
All current patients will sign new consents effective 11/2/2020 to ensure that active patient records are in compliance.
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