INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12 - 14, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Safe Harbor Behavioral Health of UPMC Hamot 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 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to develop a written procedure that was compliant with Federal and State confidentiality regulations based on a review of the facility's policy manual on March 12 - 14, 2019.The facility's confidentiality policy and procedure stated that without the consent of the client the facility could release information to the following: judges who have imposed sentence on a client where such sentence is conditioned upon the client entering a project, probation or parole officers who have assigned responsibility to clients in treatment if the probation or parole is conditioned upon his being in treatment and judges who have assigned a client to a project under pre-sentence, conditional release program. This is in violation of Federal and State confidentiality regulations 42 CFR, Part II, Subpart C and 71 P.S.1690.108 (b) which requires written client consent.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Director of Regulatory Compliance will have this policy updated to be in accordance with Federal and State confidentiality regulationsby 4/30/2019.
2. The Executive Director and Medical Director will have reviewed these changes by 4/30/2019. In addition, the changes will be reviewed with the Board of Directors by 4/30/2019. |
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
The facility failed to document an informed and voluntary consent from the client prior to the disclosure of information contained in the client record in one of seven client records reviewed on March 12 - 14, 2019.Client # 4 was admitted June 28, 2018 and discharged January 4, 2019. The facility released the name of the client and the diagnosis to the insurance company for billing purposes.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Privacy Officer has redesigned the workflow through the intake process to ensure appropriate releases are obtained; there is also a new workflow designed for medical records to assist with new releases when insurances change; finally, the Clinical Supervisor will be doing quality audits to ensure these workflows are working. The workflow will begin by 4/1/2019 and reporting will begin in the Quality Improvement Committee (by the clinical supervisor) by 4/30/2019.
2. The releases of information have been updated to reflect only allowable disclosure content. |
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
The facility did obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record but failed to document the specific information disclosed in seven of seven client records reviewed on March 12 - 14, 2019.The facility utilized a consent to release information form that included the following statements: "I authorize the release of any behavioral health information contained in my record" and "I authorize the release of any HIV information contained in my record".These statements were checked off yes to release this information. There was no documentation of the specific behavioral health or HIV information to be disclosed in client records # 1, 2, 3, 4, 5, 6 and 7.Client # 1 was admitted January 7, 2019.Client # 2 was admitted October 22, 2018.Client # 3 was admitted October 9, 2018.Client # 4 was admitted June 28, 2018 and discharged January 4, 2019.Client # 5 was admitted October 17, 2018 and discharged January 15, 2019.Client # 6 was admitted July 18, 2018 and discharged January 7, 2019.Client # 7 was admitted September 25, 2018 and discharged December 7, 2018.In addition, the facility exceeded the limits imposed at 4 Pa. Code 255.5 by indicating on the consent to release information form that any behavioral health and HIV information would be released to probation, funding entities and government agencies in client records # 1, 2, 3, 4, 6 and 7.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the 2018 licensing inspection.
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Plan of Correction
1. All releases of information in the substance use disorder program have been updated and are now in compliance. These updates were made by the Administrative Assistant.
2. The Director of Regulatory Compliance will assess all consent forms to ensure these changes have been fully made, by 4/30/2019.
3. The clinical supervisor will begin auditing these elements in routine chart audits by 4/1/2019 and reporting will begin in the Quality Improvement Committee (by the clinical supervisor) by 4/30/2019. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
The facility failed to develop policies and procedures to respond to the following incidents: inappropriate behavior by a patient causing disruption, an incident with potential for negative community reaction or may lead to community concern, drug related hospitalization of a patient and other unusual incidents the facility believes should be documented based on a review of the facility's policy manual on March 12 - 14, 2019.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Director of Regulatory Compliance will have this policy updated to be in compliance by 4/30/2019.
2. The Executive Director and Medical Director will have reviewed these changes by 4/30/2019. In addition, the changes will be reviewed with the Board of Directors by 4/30/2019.
3. The clinical supervisor will provide training to all staff on the updated policy by 4/30/2019.
4. The clinical supervisor will ensure implementation of the policy by directing staff to complete incident reports as incidents are identified and/or providing remediating education should an incident not be reported in a timely way. |