INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 22-23, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Mountain Laurel Recovery Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate client's treatment and include the reason for termination in five out of five records reviewed.Client # 1 was admitted on October 14, 2021 and administratively discharged on November 9, 2021Client # 2 was admitted on November 1, 2021 and administratively discharged on November 13, 2021Client # 3 was admitted on November 1, 2021 and administratively discharged on December 28, 2021Client # 4 was admitted on January 18, 2022 and administratively discharged on January 23, 2022Client # 5 was admitted on December 2, 2021 and administratively discharged on December 19, 2021
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Plan of Correction
MLRC has made a letter that specifically dictates the decision to administratively discharge the individual from treatment, as well as reason and rationale for this decision being made. This letter will be given to the individual at the time of discharge so that they have been made aware of the decision and why. A copy of the letter given to the client will be uploaded to their chart in the EMR in order to maintain record of this. The Clinical Supervisor will ensure that all members of the Clinical Team and Leadership Team have a copy of this letter and detailed instruction on how to complete and deliver it to the client being administratively discharged will be delivered to the Clinical Team and the Leadership Team by the Director of Quality & Development and Clinical Supervisor. The Director of Quality & Development will, when auditing files, audit for a letter in the file when the client chart being audited has been administratively discharged. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a completed client record, which is to include a discharge summary, in one out of five records reviewed.Client # 2 was admitted on November 1, 20221 and discharged on November 13, 2021. The client record did not contain documentation of a discharge summary.
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Plan of Correction
MLRC will ensure that all discharge summaries are completed per DDAP Regulation and Policy. Discharge summaries will be completed and entered in to the clients record within 72 hours of discharge from the program. Discharge summaries will be complete with all information required and entered in the EMR. DQI and Compliance Agent, with assistance from Clinical Supervisor and Clinical Director, will audit client files to ensure that discharge summaries are complete. Discharge summaries found incomplete will be corrected by the appropriate counselor.
Noncompliant Charts will be corrected by the Clinical Supervisor no later than 4/29/2022. Clinical Supervisor will complete the discharge summary with information surrounding the discharge and other information required by the summary. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record which includes notifying the emergency contact in two out of five records reviewed. Per the facility's Transition/Discharge policy, the emergency contact is to be notified within no more than twelve hours of an administrative discharge.Client # 2 was admitted on November 1, 2021 and discharged November 13, 2021. The client record did not contain documentation of emergency contact notification within twelve hours of administrative discharge.Client # 5 was admitted on December 2, 2021 and discharged on December 19, 2021. The client record did not contain documentation of emergency contact notification within twelve hours of administrative discharge.
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Plan of Correction
MLRC will ensure that all contacts are made to family members and emergency contacts, when necessary, specifically when discharged from the program administratively. These contacts will be completed per DDAP Regulation and Policy. Contacts will be completed and entered in to the clients record within 12 hours of leaving the program atypically (left against staff advice, administratively discharged or transferred to a medical, psychiatric or other treatment facility) and 24 hours when discharged from the program as anticipated. All contacts will be complete with all information required and entered in the EMR. DQI and Compliance Agent, with assistance from Clinical Supervisor and Clinical Director, will audit client files to ensure that contacts are complete and timely. Contacts that are found incomplete or have not been made will be corrected by the appropriate counselor. |