INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, John F. Kennedy Behavioral Health 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:
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Plan of Correction
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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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent form from the client for the disclosure of information contained in the client record in one of seven records reviewed.
Client #5 was admitted on May 10, 2021 and was discharged on September 14, 2022. The funding source release of information form expired on June 25, 2022 and there was documentation of billing to the funding source after that date; however, there was no updated release of information form documented in the record.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Every active client in treatment will meet in-person with their counselor to complete annual releases of information. Every consent form, including but not limited to: funding source; transportation agency; primary care physician; and emergency contact will contain the dated signature of the client. The Unit Director, prior to approving clinical service notes to be submitted for billing, will ensure that there is an active voluntary release of information for the funding source with a physical signature of both the client and the witness. Notes that do not comply with this procedure will be held back for submission until the person has signed the required release of information form. Quality Assurance Director/or designee will monitor the implementation of this procedure during compliance review of charts. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of a client on informed and voluntary consent to release information forms in one of seven client records reviewed.
Client #6 was admitted on February 21, 2019 and was discharged on April 5, 2022. There was a release of information form to a funding source signed by a witness on August 24, 2021; however, the release form did not include the signature of the client.
This is a repeat citation from the November 3, 2021 annual licensing renewal inspection.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Every active client in treatment will meet in-person with their counselor to complete annual releases of information. Every consent form, including but not limited to: funding source; transportation agency; primary care physician; and emergency contact will contain the dated signature of the client and the witness. In the Electronic Medical Record a notification will be entered into each client's chart to provide the therapist and supervisor with a visual reminder. The Unit Supervisor will review client records on a regular basis during individual supervision to ensure that all informed and voluntary release of information forms are signed and dated by the client. The Unit Supervisor will monitor the completion of the annual consent packet two months prior to expiration date recorded in the Electronic Medical Record in order to ensure full compliance with the regulatory requirements. Quality Assurance Director/or designee will monitor the completion and compliance of this practice during chart reviews. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of the unusual incident report logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an off-site client death that was reported to the facility on February 28, 2022.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
JFK will file a written unusual incident report with the Department of Drug and Alcohol Programs within 3 business days following an unusual incident involving but not limited to death, or serious injury due to trauma, suicide, medication error or unusual circumstances. The Unit Supervisor has the responsibility of preparing the unusual incident report and will upload the report to DDAP's Unusual Incident Reporting and Electronic Reporting System (ERS). The Unit Director will also provide a copy of the submitted unusual incident report to Quality Assurance Director/or designee for additional monitoring for the submission of the form. |