INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Montgomery County MH/MR Emergency Service, Inc. 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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709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.
Client # 5 was admitted on November 24, 2023 and discharged Against Medical Advise (AMA) on December 8, 2023. The facility failed to follow their policy related to AMA discharges of calling the emergency contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The Discharge Policy includes the need to notify the emergency contact at the time of the AMA discharge. The Social Service Director was notified of the citation and redistributed the Discharge Policy to all caseworkers and re-educated them on the need to notify the patient's emergency contact, with the proper written consent, at the time of the AMA discharge. Each caseworker completed an acknowledgement indicating they received the Discharge Policy. A prompt regarding the need to contact the emergency contact has been added to the aftercare plan section of the EMR as a reminder for caseworkers. PI/RM Director and Medical Director will review all AMA discharges to monitor compliance. Information will be provided to the Social Service Director in instances of non-compliance. |
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
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in two records reviewed.
Client # 1 was admitted on January 6, 2024 and was active at the time of the inspection. The record contained documentation of a disclosure of information to a family member on January 8, 2024; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure. Additionally, the record contained documentation of a disclosure of information to a treatment provider on January 12, 2024; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 4 was admitted on October 8, 2023 and discharged on October 10, 2023. The record contained documentation of a disclosure of information to a document management company on October 12, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 - The Social Service Director was notified of the citation and the Confidentiality Policy was redistributed to all caseworkers. The Social Service Director re-educated them on the need to always obtain a written consent prior to releasing any information. Each caseworker completed an acknowledgement indicating they received the Confidentiality Policy. Compliance with the policy will be reviewed during the discharge audit process by the PI/RM Department staff. Information will be provided to the Social Service Director in instances of non-compliance.
Client #4 - This patient was administratively discharged, so no release form was obtained from the patient. As a result of the administrative discharge, a report to DDAP was required, which was submitted via fax. We utilize a contracted fax service, but did not have a Business Service Agreement for those services. We have obtained a signed Business Service Agreement. The DDAP portal is now set-up and will be used for all future submissions. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of seven client records, the facility failed to include documentation of all the required client rights, including that the project may not discriminate in the provision of services on the basis of ethnicity, marital status, or sexual orientation in all seven records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The patient rights section of the patient/family handbook was updated during the survey process and now contains all 11 components, including ethnicity, marital status and sexual orientation. Each patient receives a copy of the patient/family handbook upon admission.
On 2/20/24 all patients who were active during the 1/25/24 survey were presented with a new copy of the Patient/Family Handbook with the additional rights. This was done by the Allied Therapy Director. Any patients admitted since the 1/25/24 survey have received the updated version of the Patient/Family Handbook. The Administrative Support Services Director oversaw this process and was responsible for the plan of correction. |
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 seven client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.
Client # 4 was admitted on October 8, 2023 and was administratively discharged on October 10, 2023. There was no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A letter has been developed to provide patients who are administratively discharged from the hospital. The reason(s) for the discharge are outlined in the letter. The letter will be auto-generated from the EMR, signed by the Medical Director and provided to the patient, along with their other discharge paperwork, upon discharge. If the patient is unwilling or unable to take the letter, it will be mailed to their address on file. All administrative discharges will be reviewed by the Medical Director within 24 hours to ensure compliance. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of seven client records and a discussion with facility staff, the facility failed to ensure that a physical assault by a client was reported to the Department within three business days.
Client # 2 was admitted on December 30, 2023 and was active at the time of the inspection. The client record contained documentation of the client being physically assaultive on January 6, 2024, however, the incident was not reported to the Department.
This is a repeat citation from the March 23, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This incident was internally categorized as a behavioral incident as it took place during a restraint process. However, going forward all behavioral incidents will be reviewed in detail by the PI/RM Director who will consult with the Medical Director regarding any questions about there being a physical assault of staff and/or other patients. Incidents involving assault will then be reported as per the policy. A summary of all incidents reported monthly will be reviewed at the Environment of Care Committee. |