INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 23, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gate House Behavioral Health Services 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:
|
Plan of Correction
|
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.
|
Observations
Ten client records were reviewed on February 23, 2017. The facility failed to obtain a consent to release information form for information released to a company in one of ten client records reviewed, specifically client record #1.
Client #1 was admitted into treatment on September 19, 2016 and was still an active client at the time of the inspection. The client record contained documentation indicating that the facility released patient identifying information to a company that provides support services on January 24, 2017 and failed to obtain an informed and voluntary consent prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Confidentiality:
- As of 2/24/17, proper documentation for the disclosure of information contained in the client record has been obtained for client #1, who is an active client. The Program Director retrained all clinical and relevant administrative staff on the completion of consent forms, as of 3/1/17. Program Director will review charts for proper consents during monthly supervision and associated chart review for the next 3 months.
|
709.93(a) 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:
|
Observations
Ten client records were reviewed on February 23, 2017, six of which required documentation of case consultations. The facility failed to document a case consultation in three of the six records requiring case consultations. Specifically, in client records #6, #7 and #8.
Client #6 was admitted on July 26, 2016 and was discharged on October 25, 2016.
Client #8 was admitted on July 25, 2016 and was discharged on November 9, 2016.
Client #10 was admitted on August 11, 2016 and was discharged on November 22, 2016.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
- Program Director updated internal policy to reflect appropriate markers and treatment indicators to trigger case consultations and when to conduct them, and conducted a training with clinical staff members on 3/8/17 to address the required documentation of case consultations as such. Any client charts closed on 3/8/17 or after will include a case consultation, and be in compliance with this regulation.
- To ensure compliance the Program Director will review a sampling of closed charts, specifically for case consultations, for a period of 3 months.
|