INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, 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 September 17, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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, UPMC Behavioral Health of the Alleghenies 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 the review of client records on September 17, 2020, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client record #7. Client #7 was admitted on May 31, 2019 and discharged on June 25, 2019. A consent to release form was dated May 31, 2019 to the funding source that allowed for the release of consults, discharge summary/instructions, laboratory reports/tests, medical history and physical exam, medication records, physician orders, progress notes and psychiatric/psychological eval. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Re-education for staff will be conducted by the Compliance/Risk Officer by Nov. 5, 2020, to include begin and end dates and timeframes that make an authorization to release information valid as well as information within the limits that can be released. The Facility Director will monitor releases through a monthly chart audit and if percentage falls below 90% disciplinary action will be taken on an individual basis. |
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 the review of client records on September 17, 2020, the facility failed to document an informed and voluntary consent to release information form with what specific information could be disclosed in client #5. Client #5 was admitted on January 27, 2020 and discharged on April 7, 2020. Two consent to release information forms dated January 27, 2020 to a treatment facility and a government agency did not list what information could be released. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Re-education of all drug and alcohol staff will be conducted by the Compliance/Risk officer by Nov. 5, 2020 to include the reason for the release and what information can be released for a provider or government agency. The Facility Director will monitor releases through a monthly chart audit and if percentage falls below 90% disciplinary action will be taken on an individual basis. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records on September 17, 2020, the facility failed to document an informed and voluntary consent to release information form with the purpose of disclosure in client #'s 4 and 5.Client #4 was admitted on July 31, 2019 and discharged on April 7, 2020. The client record had nine releases of information without the purpose listed. All the consent to release information forms were dated July 31, 2019. Eight of the forms were to treatment facilities and one was to a funding source. Client #5 was admitted on January 27, 2020 and discharged on April 7, 2020. The client record had four releases of information without the purpose listed. All the forms were dated January 27, 2020. Three of the forms were to treatment facilities and one was to a government agency. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Re-education of all drug and alcohol staff to include the purpose for the release of information. Education will be conducted by the Compliance/Risk officer by Nov. 5, 2020. The Facility Director will monitor releases through a monthly chart audit for the next 3 months and if percentage falls below 90% individual disciplinary action will be taken. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on the review of client records on September 17, 2020, the facility failed to document an informed and voluntary consent to release information with a valid witness signature in client #1. Client #1 was admitted on June 26, 2020 and was still active at the time of the inspection. A release of information form was dated by the client on October 2020 (the day of the month was not legible). The witness signature was dated June 26, 2020. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Re-education of all drug and alcohol staff to include the signature process being legible and appropriately witnessed for the release of information. Education will be conducted by the Compliance/Risk officer by Nov. 5, 2020. The Facility Director will monitor releases through a monthly chart audit for the next 3 months and if percentage falls below 90% individual disciplinary action will be taken. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records on September 17, 2020, the facility failed to document an informed and voluntary consent to release information with an expiration date in client record #1.Client #1 was admitted on June 26, 2020 and was still active at the time of the inspection. The release of information dated October 2020 (the day of the month was not legible on the form) to a healthcare facility did not have an expiration date. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Re-education of all drug and alcohol staff to include the signature process being legible and appropriately witnessed for the release of information. Re-education will also include the necessity for legibility. Education will be conducted by the Compliance/Risk officer by Nov. 5, 2020. The Facility Director will monitor releases through a monthly chart audit for the next 3 months and if percentage falls below 90% individual disciplinary action will be taken. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records on September 17, 2020, the facility failed to document an informed and voluntary consent to release information with documentation that the client was offered a copy in client records #1, 5 and 6.Client #1 was admitted on June 26, 2020 and was still active at the time of the inspection. A release of information dated October 2020 (the day of the month was not legible) was to a healthcare facility. Client #5 was admitted on January 27, 2020 and discharged on April 7, 2020. Two releases of information dated January 27, 2020 were to treatment facilities. Client #6 was admitted on June 22, 2020 and was still active at the time of the inspection. Two releases of information dated June 22, 2020 were to a funding source and a treatment facility. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Re-education of all drug and alcohol staff to include the necessity for checking whether the client received or refused a copy of the release demonstrating appropriate consent. Education will be conducted by the Compliance/Risk officer by Nov. 5, 2020. The Facility Director will monitor releases through a monthly chart audit for the next 3 months and if percentage falls below 90% individual disciplinary action will be taken. |