INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 14, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, UPMC Western Behavioral Health at Safe Harbor 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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record # 7.
Client # 7 was admitted on April 14, 2022 and was discharged June 15, 2022. A review of client records indicated funding was being provided. There was not an informed and voluntary consent from the client for the disclosure of information in the client record to a funding source.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 5/31/23 Program Manager will review the specifics of the citation with staff and provided education to staff on 709.28. Confidentiality.
OP staff will obtain complete releases of information prior to disclosure of client records.
This element will be incorporated into the Program Managers monthly chart audits, which are part of the quality assurance committee's monthly reporting.
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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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record to include a dated signature of the client.
Client # 1 was admitted on September 12, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated September 15, 2022 to a funding agency did not have a valid signature by the client. Authorizations for funding occurred on September 14, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 5/31/23 Program Manager will review the specifics of the citation with staff and provided education to staff on 709.28. Confidentiality.
OP staff will obtain complete releases of information prior to disclosure of client records.
This element will be incorporated into the Program Managers monthly chart audits, which are part of the quality assurance committee's monthly reporting.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on five of seven client records reviewed, the facility failed to provide a comprehensive treatment plan in accordance with the facility policy and procedure manual. The policy and procedure manual indicates a comprehensive treatment plan be developed on the third session with the client.
Client # 1 was admitted on September 12, 2022 and was still active at the time of the inspection. The third session with the client occurred on October 5, 2022. A comprehensive rehabilitation and treatment plan did not occur until November 17, 2022.
Client # 3 was admitted on May 16, 2022 and was still active at the time of the inspection. The third session with the client occurred on June 27, 2022. A comprehensive rehabilitation and treatment plan did not occur until July 12, 2022.
Client # 4 was admitted on June 22, 2022 and was still active at the time of the inspection. The third session with the client occurred on August 15, 2022. A comprehensive rehabilitation and treatment plan did not occur until September 7, 2022.
Client # 5 was admitted on May 4, 2022 and was discharged January 9, 2023. The third session with the client occurred on June 23, 2022. A comprehensive rehabilitation and treatment plan did not occur until July 6, 2022.
Client # 7 was admitted on April 14, 2022 and was discharged June 15, 2022. The third session with the client occurred on May 23, 2022. A comprehensive rehabilitation and treatment plan did not occur.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program manager will update AMS program guidelines by 5/31/2023 to indicate that a "treatment plan" will be developed at the time of initial assessment/intake if treatment is warranted and every 60 days following.
Program Manager will monitor this charting element in monthly audits, which are then reported to the Quality Assurance Committee and will be reviewed for future clients.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on two of five applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records #4 and # 5.
Client # 4 was admitted on June 22, 2022 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on October 24, 2022. A treatment and rehabilitation plan update was due no later than December 24, 2022. A treatment and rehabilitation plan update did not occur until January 6, 2023.
Client # 5 was admitted on May 4, 2022 and was discharged on January 9, 2023. A treatment and rehabilitation plan was developed on October 24, 2022. A treatment and rehabilitation plan update was due no later than December 24, 2022. There was no documentation of a treatment plan update in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager will review requirements with outpatient staff to ensure reviews are completed at least every 60 days, even if the individual in services is not present. Staff will be trained on this element by 5/31/23.
Program Manager will monitor this charting element in monthly audits, which are then reported to the Quality Assurance Committee and will be reviewed for future clients.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on two of two applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur within five business days after discharge by phone.
Client # 5 was admitted on May 4, 2022 and was discharged on January 9, 2023.
There was no follow-up information available in the client record.
Client # 7 was admitted on April 14, 2022 and was discharged on June 15, 2022.
There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager reviewed requirements with outpatient staff and support staff to ensure follow up is in accordance with the facility guidelines/policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur within five business days after discharge by phone. Staff will be trained by 5/31/23.
Program Manager will monitor this charting element in monthly audits, which are then reported to the Quality Assurance Committee and will be reviewed for future clients.
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