INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone/buprenorphine monitoring conducted on August 13, 2024 through August 14, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard DD/FIR 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) (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 a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in four of fourteen client records reviewed.
Client #2 was admitted to the residential activity on July 12, 2024 and was active at the time of inspection. A release of information form to a government agency was signed by the client on July 12, 2024, but the form did not include the purpose of the disclosure.
Client #4 was admitted to the residential activity on March 4, 2024 and was discharged on April 20, 2024. A release of information form to a government agency was signed by the client on March 4, 2024, but the form did not include the purpose of the disclosure.
Client #9 was admitted to the detox activity on August 10, 2024 and was still active at the time of inspection. A release of information form to a government agency was signed by the client on August 10, 2024, but the form did not include the purpose of the disclosure.
Client #14 was admitted to the detox activity on May 2, 2024 and was discharged on May 7, 2024. A release of information form to a government agency was signed by the client on May 2, 2024, but the form did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
# Clinical supervisor will client # 2, 4 and 9 with assigned counselor(s) to discuss importance of documenting the purpose of the disclosure on consent forms
Responsible: Clinical Supervisor and Therapists
Date of completion: 09/13/24
2. Clinical Supervisor will provide a in-service training to all staff regarding the proper completion of consents and what triggers a need for a consents and purpose of the disclosure to prevent reoccurrence.
Responsible: Clinical Supervisor
Date of completion: 09/13/24
3.Clinical Supervisor will conduct random audits of five (5) charts per clinician each month to validate that staff members are correctly completing consent forms
Responsible: Clinical Supervisor
Date of completion: 09/13/24 |
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 a review of client records, the facility failed to ensure a copy of a consent to release information form was offered to the client in two of fourteen client records reviewed.
Client #8 was admitted to the detox activity on August 9, 2024 and was still active at the time of the inspection. A release of information form to a social service agency was signed by the client on August 9, 2024; however, there was no documentation, in the record, indicating a copy of the consent form was offered to the client.
Client #13 was admitted to the detox activity on April 13, 2024 and was discharged on April 19, 2024. A release of information form to a social service agency was signed by the client on April 13, 2024; however, there was no documentation, in the record, indicating a copy of the consent form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
# Clinical supervisor will client # 8 and 13 with assigned counselor(s) to discuss importance of ensure a copy of a consent to release information form was offered to the client
Responsible: Clinical Supervisor and counselor
Date of completion: 09/13/24
# Clinical supervisors will provide supervision on consents requirements per DDAP regulation
Responsible: Clinical Supervisor
Date of completion: 09/13/24
# Clinical supervisor will review consent/ROI forms to assure forms contain required client offer of copy
on utilized form check box
Responsible: Clinical Supervisor
Date of completion: 09/13/24
#. Clinical Supervisor will document outcome of consent audits in Performance Improvement report
Responsible: Clinical Supervisor
Date of completion: on-going
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715.20(3) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(3) The transferring narcotic treatment program shall document what materials were sent to the receiving narcotic treatment program.
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Observations
Based on a review of patient records, the narcotic treatment program failed to document what materials were sent to the receiving narcotic treatment program upon a patient transfer in one of one applicable patient record reviewed.
Patient #11 was admitted to the detox activity on March 14, 2024 and was transferred to an outpatient narcotic treatment program on March 19, 2024. There was no documentation, in the record, indicating the exact materials that were sent to the receiving narcotic treatment program.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
# Due to participant's discharge prior to inspection the narcotic treatment program was unable to correct failure to document what materials were sent to the receiving narcotic treatment program upon a patient transfer
# Clinical supervisors will provide supervision and an onsite training on transfer document requirements for external providers per DDAP regulation
Responsible: Clinical Supervisor
Date of completion: 09/13/24
#Counselor will assure applicable Transfer documentation provided to external providers will be scanned/evidenced into client EMR chart: including last dose /Dose verification fax, confirmation, and document transfer coordination in note
Responsible: Clinical Supervisor and counselor
Date of completion: 09/13/24
#Counselor will document required information in respective client EMR note of coordination for admission transfer of client
Responsible: Clinical Supervisor and counselor
Date of completion: 09/13/24
#Supervisors will focus monitor 5 respective, random transfer charts per month for 60 days for respective client transfer documents for transfer to external providers per requirements per DDAP & BWC policy
Responsible: Clinical Supervisor
Date of completion: 09/13/24
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