INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 26, 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) (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
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information which included specific information to be disclosed, in one of seven records reviewed.
Client #2 was admitted on August 9, 2023 and still a current client at the time of the inspection. A release of information was signed to an agency on August 9, 2023 which did not include specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ON 10/27/2023 PROGRAM DIRECTED REVIEWED THE SPECIFICS OF THE CITATION WITH STAFF AND PROVIDED EDUCATION ON CONFIDENTIALITY AND COMPLETING RELEASE OF INFORMAITON.
OUTPATIENT STAFF WILL OBTAIN COMPLETE RELEASES OF INFORMATION IN FULL PRIOR TO DISCLOSURE OF CLIENT RECORDS.
STAFF WILL COMPLETE RELEASES IN FULL WITH THE PATIENT AND IDENTIFY SPECIFIC INFORMATION TO BE RELEASED.
THIS ELEMENT WILL CONTINUE TO BE INCORPORATED IN MONTHLY CHART AUDITS, WHICH ARE PART OF THE QUALITY ASSURANCE COMMITTEE'S MONTHLY REPORTING. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to complete case consultations according to agency policy and procedure manual timeframes in two out of three applicable records reviewed.
Agency P&P states each client ' s progress is reviewed at least once quarterly via case consultation in a multi-disciplinary or peer team. Case consultation can be held more often if need be and may be held annually for clients who are in treatment beyond one year.
Client #6 was admitted on April 4, 2023 and still a current client at the time of inspection. Client #6 case consultation was due by July 4, 2023 but not completed until October 2, 2023.
Client #7 was admitted on May 3, 2023 and still a current client at the time of inspection. Client #7 case consultation was due by August 3, 2023 but not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/27/23 Program Director reviewed requirements with outpatient staff to ensure case consult reviews are completed in accordance to our policy and procedures. Staff will complete at least quarterly, at the time of ASAM reviews, and if there is a significant change with a clients status.
As of December 2023, the Program Director 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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