INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection concluding on March 4, 2021 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) (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 the client, in writing, on the consents to disclose information in four of seven client records.Client #2 was admitted on October 19, 2020 and was discharged on February 1, 2021. The consents to release information did not include the client's written signature. Telehealth exception was written in place of the client's signature.Client #3 was admitted on September 30, 2020 and was discharged on February 9, 2021. The consents to release information did not include the client's written signature. Telehealth exception was written in place of the client's signature.Client #4 was admitted on December 22, 2020 and is currently an active client. The consents to release information did not include the client's written signature. Telehealth exception was written in place of the client's signature.Client #5 was admitted on December 29, 2020 and is currently an active client. The consents to release information did not include the client's written signature. Telehealth exception was written in place of the client's signature.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.)Program Manager and Clinical Supervisor will redesign the workflow with staff through intake process to ensure that a valid release of information is obtained. The Privacy Officer will not release any confidential information without a valid release on file.
2.)The Clinical Supervisor will complete quality audits through monthly chart reviews to ensure the workflow is working. The workflow will begin by 4/1/2021 and will report out to the Director of Regulatory Compliance monthly. |
715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of client records, the facility failed to document an emergency contact in one of five client records.Client #5 was admitted on December 29, 2020 and is currently an active client. There was no emergency contact documented in client record #5.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.) Upon the first visit for a medication assisted treatment, the MAT nurse will verify that there is valid release of information for the individual's emergency contact if this has not already been done through the intake process.
2.) The MAT nurse will complete quality audits through a tracking tool to ensure the workflow is working. The workflow will begin by 4/1/2021 and will report out to the Director of Regulatory Compliance monthly. |
715.14(a) LICENSURE Urine testing
(a) A narcotic treatment program shall complete an initial drug-screening urinalysis for each prospective patient and a random urinalysis at least monthly thereafter.
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Observations
Based on a review of client records, the facility failed to document monthly urine screens in two of four client records.Client #6 was admitted on July 9, 2020 and is currently an active client. There was no urine screens documented for the months of November and December 2020 as well as January and February 2021.Client #7 was admitted on December 16, 2019 and is currently an active client. There was no urine screens documented for the months of June, July, August, September, October and November 2020 as well as January and February 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.) The MAT nurse will complete an initial urine drug screen upon intake on each patient and verify that there are monthly urine drug screens being conducted each month at a minimum on each patient. Each participant will be added to a tracking tool so that monthly urine drug screens will be tracked and monitored.
2.) The MAT nurse will complete quality review through tracking tool to ensure the workflow is working. The workflow will begin by 4/1/2021 and will report out to the Director of Regulatory Compliance monthly.
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