INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 20, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mercy Behavioral Health 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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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written acknowledgement by the client that they were notified of all of their rights in seven of seven client records reviewed during the annual licensing inspection conducted on November 20, 2017.
There was no documentation that the client was informed that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection, if determined detrimental; reason for removal would be documented in the client's record in client records # 1, 2, 3, 4, 5, 6 and 7.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director, in conjunction with the Health Information Management Director, will ensure that staff make all clients of Pittsburgh Mercy aware of their rights, and document the client's written acknowledgement in their record. Staff will do this by handing out and going through our Notice of Privacy Practices and Health Information Rights document.
The below information will be inserted into our Notice of Privacy Practices and Health Information Rights document, verbatim:
"The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.""
This will be completed by December 22nd, 2017.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to document treatment plan updates at least every 60 days in four of six outpatient client records reviewed during the annual licensing inspection conducted on November 20, 2017.
Client # 1 was admitted May 31, 2017. The individual treatment plan was completed May 31, 2017. No treatment plan updates were documented.
Client # 2 was admitted March 6, 2017. The individual treatment plan was completed March 7, 2017. Only one treatment plan update was documented on November 13, 2017.
Client # 4 was admitted January 17, 2017 and discharged on August 14, 2017. The individual treatment plan was completed March 8, 2017. No treatment plan updates were documented.
Client # 5 was admitted February 17, 2017 and discharged October 12, 2017. The individual treatment plan was completed February 17, 2017. Only one treatment plan update was documented on March 27, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director and clinical supervisors will ensure that their staff members receive in-person training regarding the requirements to complete treatment plans on Drug and Alcohol clients every 60 days. This will be communicated to staff by 1-15-18.
The facility director and clinical supervisors will conduct random chart audits quarterly to ensure compliance with the regulation. This began prior to the Monitoring Visit on 11-17-17, and is on going.
Additionally, Pittsburgh Mercy is in the process of incorporating Engagement Care Management into our Outpatient Teams. Their role is to ensure timeliness of communication and documentation with our persons served. These positions were filled as of 12-1-17.
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