INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 3, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Central Montgomery MH/MR Center 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 and a plan of correction is due on October 6, 2008.
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Plan of Correction
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of six client records on September 3, 2008, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in six of six client records reviewed.
Findings:
The consent to release information forms contained language such as "release to" and/or "obtain from" which does not provide for an informed consent. These forms were found in six of six client records reviewed, #1, 2, 3, 4, 5 and 6. The consent to release information form also stated that the client could only revoke the written consent in writing, though the facility is required to honor verbal revocations as well.
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Plan of Correction
Facility Director will develop a new release form for "release to" only. The Facility Director will re-write the release form to include the statement that clients can revoke a release either verbally or in written, dated communication to the therapist or the CORE Program Director. The Facility Director will inform staff of changes 10/1/08. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of six client records on September 3, 2008, the facility failed to document a completed medical history.
Findings:
Based on a review of six client records, two were required to have a completed medical history. The medical history was missing in one of two client records where required #6.
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Plan of Correction
Facility Director developed a new Biopsychosocial Assessment Form and showed changes to staff 8/18/08. Staff were instructed on 9/15/08 to provide more details in the medical history section. Staff were instructed to document any medical hospitalizations, surgeries, or significant medical treatment episodes. Staff were instructed to document if a client does not have any significant medical history stated above. The Facility Director will use Utilization Reviews monthly to ensure therapists are documenting detailed medical histories on the Biopsychosocial Form. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records on September 3, 2008, the facility failed to document a completed drug/alcohol history.
Findings:
Based on a review of six client records, two were required to have a completed drug/alcohol history. The drug/alcohol history was missing in one of two client records where required, #6.
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Plan of Correction
Facility Director developed a new Biopsychosocial Assessment Form. Staff were trained on the new form 8/18/08 to provide a comprehensive drug/alcohol history. Staff were asked to document the progression of drug/alcohol use; patterns of substance use; as well as periods of sobriety. Facility Director will do Utilization Reviews monthly to ensure staff are documenting a comprehensive drug/alcohol history on the Biopsychosocial Form. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of six client records on September 3, 2008, the facility failed to document a completed personal history.
Findings:
Based on a review of six client records, two client records were required to have a completed personal history. The personal history was missing in one of two client records where required #6.
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Plan of Correction
Facility Director developed a new Biopsychosocial Assessment Form and trained staff 8/18/08. Staff were instructed on 9/15/08 to provide a detailed personal/family history on the Biopsychosocial Form. Facility Director will use Utilization Reviews monthly to ensure staff are properly documenting detailed personal/family histories on the Biopsychosocial Form. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on September 3, 2008, the facility failed to document a completed psychosocial evaluation.
Findings:
Based on a review of six client records, two were required to have a completed psychosocial evaluation. The psychosocial evaluation was missing in one of two client records where required, #6.
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Plan of Correction
Current policy regarding due dates for the Biopsychosocial Assessment Form is to be completed within 30 days from initial assessment or within the first four individual therapy sessions. Facility Director will change the current policy to state the Biopsychosocial Assessment Form will be completed within the first four individual therapy sessions for OP therapy clients and within the first 30 days from the initial assessment for IOP clients. Facility Director will inform staff of policy changes on 10/1/08. Facility Director will use Utilization Reviews monthly to ensure Biopsychosocial Forms are completed within expected timeframes. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of six client records on September 3, 2008, the facility failed to document proposed types of support services on the treatment plan.
Findings:
Based on a review of six client records, two client records were required to have completed treatment plans with proposed support services documented. Proposed support services were missing in two of two client records where required, #1 and 3.
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Plan of Correction
Facility Director will re-write the treatment plan to designate a section to document supportive services. Staff were informed on 9/15/08 to document any supportive services clients are receiving. Facility Director will present the new treatment plan form to staff on 10/1/08. Facility Director will use Utilization Reviews monthly to ensure therapists are properly documenting supportive services on the treatment plans. |
709.93(a)(10) LICENSURE Client records
709.93. 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 six client records on September 3, 2008, the facility failed to document a discharge summary.
Findings:
Based on a review of six client records, three records were required to have a completed discharge summary. The discharge summary was missing in one of three client records, #4.
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Plan of Correction
Facility Director informed staff on 9/15/08 the need to completely fill out a discharge summary. Facility Director will review all discharge summaries to ensure they are filled out in its entirety. |
709.93(a)(11) LICENSURE Client records
709.93. 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 the facility's policy and procedure manual and six client records on September 3, 2008, the facility failed to follow their own policy on conducting follow-up on discharged clients.
Findings:
The facility policy and procedure requires staff to conduct follow-up attempts on discharged clients three months post-discharge and one year post-discharge. Based on a review of six client records, three client records were required to have follow-up information documented. Follow-up was missing in three of three client records where required, #4, 5 and 6. According to information obtained during interviews with staff, the facility was only conducting follow-up information one year post-discharge.
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Plan of Correction
Facility Director will ensure staff follow current policy of conducting follow-up interviews three months and one year post-discharge. Facility Director will monitor discharges monthly to ensure documentation of follow-up interviews occurs. |