INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 2024 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 three of seven records reviewed. Client #2 was admitted May 7, 2024 and discharged August 13, 2024. A release of information was signed to the insurance and a government agency on May 7, 2024 which did not include specific information to be disclosed. Client #6 was admitted July 8, 2024 and still a current client. A release of information was signed to the insurance, the emergency contact, and a government agency on July 8, 2024 which did not include specific information to be disclosed. Client #7 was admitted August 12, 2024 and still a current client. A release of information was signed to the insurance and a government agency on August 12, 2024 which did not include specific information to be disclosed. These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the October 26, 2023 licensing renewal inspection.
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Plan of Correction
On 10/17/24 Program Director reviewed the specifics of the citation with staff and provided education on confidentiality and completing releases of information.
AMS staff will not be able to obtain an ROI for client #2 due to being discharge from services.
AMS Staff will obtain a new ROI for client #6, as this client is still in services. The ROI will have all elements completed including specific information to be releases.
AMS Staff will obtain a new ROI for client #7, as this client is still in services. The ROI will have all elements completed including specific information to be releases.
Outpatient Staff will obtain and complete release of information in full prior to disclosure of client records.
This element will continue to be incorporated in monthly chart audits to ensure all elements of the release of information are completed, which is part of the quality assurance committee's monthly reporting. |
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 a review of client records, the facility failed to complete treatment plan updates at least every 60 days in five of seven records. Client #1 was admitted January 30, 2024 and discharged April 30, 2024. A treatment plan was completed on January 30, 2024 and an update was due by March 30, 2024 but not completed until April 5, 2024. Client #2 was admitted May 7, 2024 and discharged August 13, 2024. A treatment plan was completed on May 7, 2024 and an update was due by July 6, 2024 but not completed until July 8, 2024. Client #4 was admitted June 17, 2024 and still a current client. A treatment plan was completed on August 14, 2024 and an update was due by October 13, 2024 but no further updates were completed. Client #5 was admitted January 31, 2024 and still a current client. A treatment plan was completed on January 31, 2024 and an update was due by March 31, 2024 but not completed until April 5, 2024. Client #6 was admitted July 8, 2024 and still a current client. A treatment plan was completed on July 8, 2024 and an update was due by September 6, 2024 but not completed until October 11, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 10/18/24 Program Director reviewed requirements with outpatient staff to ensure treatment plan reviews are completed at least every 60 days, even if the individual in services is not present.
As of November 2024, 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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