INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 12, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Luke ' s Hospital - Sacred Heart Campus 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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710.21(b)(4) LICENSURE Admission - Detoxification
§ 710.21. Admission-detoxification.
(b) Admission procedures shall include documentation of the following:
(4) Psychosocial evaluation.
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Observations
Based on a review of patient records, the facility failed to document, as part of their admission process, a psychosocial evaluation of the patient in six of seven patient records reviewed.
Patient #2 was admitted on January 10, 2022 and was still active at the time of the inspection.
Patient #3 was admitted on November 16, 2021 and was discharged on November 18, 2021.
Patient #4 was admitted on May 31, 2021 and was discharged on June 4, 2021.
Patient #5 was admitted on August 7.2021 and was discharged on August 11, 2021.
Patient #6 was admitted on October 22, 2021 and was discharged on October 28, 2021.
Patient #7 was admitted on June 30, 2021 and was discharged on July 2, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ACTION: All detox counselors received education regarding need to complete psychosocial evaluation for all intakes on 1/24/2022. Clinical Impression (psychosocial evaluation) is required with intake documentation in the EMR (i.e. EPIC ? Clin Doc ? Progress Note) and will be completed by the counselors for patient intakes.
COMPLIANCE MONITORING: Counselor supervisor to perform 10 random chart audits per month and provide feedback to counselors for any noncompliant charts. Goal 100% compliance. Continue monthly until goal reached 3 consecutive months. Then reduced to quarterly audits.
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710.23(a) LICENSURE Patient Records
§ 710.23. Patient records.
(a) In addition to the requirements contained in § 115.32 (relating to contents), the patient ' s medical record shall contain a drug and alcohol support plan, follow-up information, and an aftercare plan, if applicable.
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Observations
Based on a review of patient records, the facility failed to document follow-up information in two of five applicable patient records reviewed.
Patient #5 was admitted on August 7, 2021 and was discharged on August 11, 2021. There was no follow-up information documented in the record as of the date of the inspection.
Patient #7 was admitted on June 30, 2021 and was discharged on July 2, 2021. There was no follow-up information documented in the record as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ACTION: All detox counselors received education on 1/24/2022 regarding inclusion of discharge follow-up information on discharge paperwork in addition to education on discharge follow up call process and. Follow-up Discharge Phone call attempt is required within 7 days. Discharge Policy revised to reflect minimum requirement.
COMPLIANCE MONITORING: Counselor supervisor to perform 10 random chart audits per month and provide feedback to counselors for any noncompliant charts.
Goal 100% compliance. Continue monthly until goal reached 3 consecutive months. Then reduced to quarterly audits.
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710.23(b) LICENSURE Patient Records
§ 710.23. Patient records.
(b) Patient records shall be kept confidential in accordance with applicable Federal drug and alcohol regulations and the confidentiality requirements in 4 Pa. Code § § 255.4 and 255.5 (relating to UDCS: confidentiality and access to information and projects; and coordinating bodies: disclosure of client-oriented information).
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Observations
Based on a review of patient records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in seven of seven patient records reviewed. Additionally, the facility failed to ensure that all the required elements for a written consent, per 42 CFR 2.31, were present on releases of information in three of seven patient records reviewed.
Patient #1 was admitted on January 10, 2022 and was still active at the time of the inspection. There was no patient-signed consent to release information form to the funding source documented in the patient record as of the date of the inspection.
Patient #2 was admitted on January 10, 2022 and was still active at the time of the inspection. There was no patient-signed consent to release information form to the funding source documented in the patient record as of the date of the inspection.
Patient #3 was admitted on November 16, 2021 and was discharged on November 18, 2021. There was no patient-signed consent to release information form to the funding source documented in the patient record prior to discharge. Additionally, there were release of information forms to a primary care physician, a parent, and another treatment provider, all signed by the patient on November 17, 2021, that did not include the specific information to be released.
Patient #4 was admitted on May 31, 2021 and was discharged on June 4, 2021. There was no patient-signed consent to release information form to the funding source documented in the patient record as of the date of the inspection. Additionally, there was a release of information form to an outside doctor, signed by the patient on June 4, 2021, that did not include the dated signature of a witness.
Patient #5 was admitted on August 7, 2021 and was discharged on August 11, 2021. There was no patient-signed consent to release information form to the funding source documented in the patient record as of the date of the inspection. Additionally, there was a release of information form to a family doctor, signed by the patient on August 9, 2021, that did not include the purpose of the disclosure and the specific information to be released.
Patient #6 was admitted on October 22, 2021 and was discharged on October 28, 2021. There was no patient-signed consent to release information form to the funding source documented in the patient record as of the date of the inspection.
Patient #7 was admitted on June 30, 2021 and was discharged on July 2, 2021. There was no patient-signed consent to release information form to the funding source documented in the patient record as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Detox Counselors received education 1/24/2022 on the Release of Information requirements inclusive of documentation completion standards and funding source.
COMPLIANCE MONITORING: Counselor supervisor to perform 10 random chart audits per month and provide feedback to counselors for any noncompliant charts.
Goal 100% compliance. Continue monthly until goal reached 3 consecutive months. Then reduced to quarterly audits.
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