INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 1-16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Ridgeview Adolescent Behavioral Health Center at Pittsburgh 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 of client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client record # 3.
Client # 3 was admitted on January 11, 2021 and was still active at the time of the inspection. There was not an informed and voluntary consent from the client for the disclosure of information for a funding source in the client record.
These findings were reviewed with facility staff during the licensing process
This is a repeat citation from July 31, 2019 and August 10, 2018 inspection.
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Plan of Correction
Executive Director will complete an intake training with the Clinical team (all counselors) and any other support staff who complete intakes by 5-10-21, and will review all intake paperwork that needs completed. Executive Director will create a check list to help insure all paperwork is completed. Executive Director and Clinical Supervisor will complete weekly audits on all admissions to ensure all paperwork is complete. |
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 to include the dated signature of client.
Client # 7 was admitted on October 30, 2020 and was discharged on December 7, 2020. Informed and voluntary consent to release forms to the Department of public welfare and a funding source were not signed and dated by the client prior to the release of information.
These findings were reviewed with facility staff during the licensing process
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Plan of Correction
Executive Director will complete an intake training with the Clinical team (all counselors) and any other support staff who complete intakes by 5-10-21, and will review all intake paperwork that needs completed. Executive Director will create a check list to help insure all paperwork is completed. Executive Director and Clinical Supervisor will complete weekly audits on all admissions to ensure all paperwork is complete.
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709.53(a)(11) LICENSURE Follow-up information
709.53. 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 three of three discharged client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 7 days of discharge.
Client # 5 was admitted on September 21, 2020 and was discharged on December 9, 2020. There was no documentation up follow-up information in the client record.
Client # 6 was admitted on October 12, 2020 and was discharged on December 9, 2020. There was no documentation up follow-up information in the client record.
Client # 7 was admitted on October 30, 2020 and was discharged on December 7, 2020. There was no documentation up follow-up information in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will review the importance of follow up calls and review the procedure for completing follow up calls, such as time frames, documentation in electronic medical record, during next Clinical meeting on 4-28-21. All Clinical staff, who complete follow up calls, will be present for review. ED or Clinical Supervisor will continue to conduct monthly chart audits to ensure compliance with 7 day follow up call being documented within the SA Call log, within the electronic medical record. |