This report is a result of an on-site licensure renewal inspection conducted on February 20, 2025, 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 Services, 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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Observations
Based on the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven records reviewed.
Client #4 was admitted on July 6, 2024 and was discharged on July 12, 2024. A release of information form for the funding source was not documented in the client record; however, the facility verified that billing had occurred.
Client #5 was admitted on June 18, 2024 and was discharged on July 8, 2024. Facility staff members communicated with the client ' s primary care physician on July 17, 2024; however, there were no release of information forms signed by the client prior to disclosures.
Client #7 was admitted on May 8, 2024 and was discharged on May 13, 2024. Facility staff members communicated with another mental health provider on May 17, 2024; however, there were no release of information forms signed by the client prior to disclosures.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
At the 3/6/25 monthly Leadership meeting, the Administrative Support Services Director/Compliance Officer distributed a memo to all clinical supervisors regarding completion of release forms and releasing confidential patient information. The memo was reviewed and discussed. The importance of obtaining the patient's written consent before releasing any confidential patient information was reiterated. Suggestions were also offered for situations when a patient declines to sign a confidential release form.
Administrative Support Staff began reviewing 100% of client records on 3/10/25 at discharge to ensure that release forms are completed as indicated. For any non-compliant records, the Administrative Support Services Director/Compliance Director will forward the information to the appropriate supervisor who will re-educate and provide corrective counseling to the employee.
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