INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and a buprenorphine monitoring inspection conducted on July 29-31, 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, Marworth 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a reviews of the facility's 2018 fire drills, the facility failed to ensure that a fire drill during sleeping hours was conducted at least every six months.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was conducted with the Security Supervisor on August 20, 2019 regarding this finding. The Supervisor is now aware that fire drills must be conducted at least every 6 months during the sleeping hours of the patients which is 2300 to 0600. The Fire Plan policy was revised to add that a fire drill is to be conducted at least every 6 months during sleeping hours. A fire drill was conducted on August 23, 2019 @ 2309. Another fire drill will be conducted in October 2019 then April 2020 during the sleeping hours. These fire drills will occur ongoing as specified in the regulation. This finding was discussed at the Performance Improvement Committee meeting on August 20, 2019 and will be shared at the next Leadership Committee meeting On August 28, 2019 by the Security Supervisor. The Security Supervisor is expected to report out these fire drills to the Leadership Committee meeting twice a year and every other month at the Safety Committee meeting. In addition, the Security Supervisor will do a monthly audit of the fire drills to ensure compliance with this regulation. This information will be reported in the monthly Performance Improvement Committee meeting. |
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 a review of client records, 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 # 24.
Client#24 was admitted on May 17, 2019 and was discharged on May 28, 2019. A consent to release form was signed and dated on May 17, 2019 to the probation officer that allowed for the release of the discharge summary.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was conducted with the Health Information Management Supervisor on August 21, 2019 regarding this finding. The following policies were reviewed: Release of Information and Authorization to Release Information. The department Directors/Managers will be re-educated regarding the disclosure of information contained in the client record. Disclosures of client identifying information need to be within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client records. An educational memorandum addressing this finding, Confidentiality, and Release of Information was issued to the responsible parties who obtain consent which includes Admissions, Counseling, Nursing, Outpatient, and Medical staff. This memorandum was sent out on August 22, 2019. Discussion of this finding with re-education has been conducted at departmental staff meetings.
Upon hire, every new employee meets with the Health Information Management Supervisor for Confidentiality training. This training includes Pennsylvania State Law 255.5. In addition, on a yearly basis, the employee completes a Geisinger Online Academic Learning System (GOALS) course entitled "Marworth Confidentiality Training".
An educational binder with examples of Authorization to Release Information forms is available to the Admissions staff. Staff are to consult the Health Information Management department with any confidentiality and release of information questions.
Health Information Management department is vigilant with conducting a double check before release of information is conducted. The Authorization for Release of Information form is reviewed for accuracy.
Medical Record Reviews will be conducted on 30 patient charts monthly to ensure that all consents to release information are completed in accordance with the limits established by 4 Pa. code 255.5(b). This review will be completed for the next 3 months. This audit information will be reported in the monthly Performance Improvement Committee meeting.
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709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of the facility policy and procedure manual as well as the client rights sign off, the facility failed to notify clients that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A meeting was conducted with the Admission Director, the Health Information Management Supervisor and Counseling Directors on August 21, 2019 regarding this finding. The following policies were reviewed: Bill of Rights, Right to Inspect Record, and Patient Initiated Amendment of Protected Health Information. The Patient's Bill of Rights in the electronic medical record and Geisinger Marworth Patient Handbook has been revised to capture the following statement, "Right ...to request the correction of inaccurate, irrelevant, outdated or incomplete information in your records." This revision was completed by August 26, 2019. This information will be presented in hard copy to the patient via the Geisinger Marworth Patient Handbook and is signed off electronically by the patient. The department Director /Manager has educated the staff regarding the revision to the Patient's Bill of Rights at a departmental staff meeting held on August 26, 2019. Discussion about this finding and the revision to the Patient's Bill of Rights will be completed at the Leadership Committee meeting on August 28, 2019 by the Admissions Director or Director of Counseling. A medical record review will be completed on August 29, 2019 to ensure that all of the client rights including the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records is present. The Health Information Management Supervisor will ensure that as a part of the regular, monthly Chart Audit process, the current version of the Patient's Bill of Rights is being completed. This information will be reported in the monthly Performance Improvement Committee meeting. |