INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 26- 27, 2011 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:
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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 the client records, the facility released information that exceeded what was permissible by 4Pa. Code 255.5(a)(6).
The findings include:
Six client records requiring consent to release information were reviewed on September 27, 2011. One of six client records reviewed contained released information that exceeded that which is permissible to be released by 4Pa. Code 255.5(a)(6), specifically record # 4.
The findings include:
Client # 4 was admitted to treatment on May 20, 2011. Client record #4 contained three letters dated 8/24/11, 8/25/11, and 8/27/11 stating the client was currently in a drug and alcohol treatment program; however the letter did not identify the recipient of the letter or the purpose for the release of information. Additionally, since there was no identified recipient or listed purpose included on the letter it was not possible to determine that a valid consent to release information had been completed.
Employee #1 confirmed the findings.
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Plan of Correction
The Facility Director will review the Confidentiality laws with the CORE staff at the next monthly CORE meeting on 10/17/11. Staff will be instructed to ask all consumers for a written release to be completed for any letters a consumer is requesting be written. If the consumer is refusing to sign a release, this will be documented in the progress notes in the chart. If the staff write a "To Whom It May Concern" letter, then the staff will document that the letter is being directly released to the consumer and why in the progress notes in the chart.
The Facility Director will make confidentiality a priority when reviewing consumer records during quality improvement reviews. The Facility Director reviews at least two charts per month. This will begin 10/17/11.
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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of employee #1's job description and the project's organizational chart, the project failed to ensure that the staff person appointed to the position of project director would be responsible for the overall management of the project and staff.
The findings include:
The published definition for project director as found in 28 Pa. Code, 701.1 is as follows:
Project director - The administrator of the treatment project who is responsible
for the overall management of the project and staff and who meets the education
and experience requirements in Chapter 704.
Employee # 1 was hired on February 1, 1997 as the Director of Outpatient Services. On September 26, 2011 employee #1's job description was reviewed along with the project's organizational chart
The job description for the Corporate Clinical Director does not specify that employee #1 is responsible for the overall management of the project and staff. Furthermore, the Organizational Chart does not indicate that employee #1 reports directly to the governing body.
Employee #1's job description does not indicate that he is responsible for executing contracts, establishing wage scales, approving personnel policies, or managing the project's fiscal matters and therefore, is not responsible for the overall management of the project.
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Plan of Correction
The Project Director presented the CORE goals and CORE Marketing and Outreach plan at the 10/13/11 Board of Directors Meeting. The Board approved these plans. The Project Director also informed the Board of Directors that it is the responsibility of the Project Director to report any issues regarding the CORE Program to the Board directly. This will be documented in the monthly Board Minutes which are kept in the CORE Policy and Procedure Manual.
The Project Director's job description will be changed to reflect that the Project Director reports to the Board of Directors regarding the CORE Program. The job description will also include the Project Director's responsibilities of executing contracts, working in coordination with the Human Resource Department, Executive Director, Board of Directors, and Accounting Department to establish wage scales for CORE personnel along with personnel policies. The job description will be completed 11/1/11.
The agency's organizational chart will also be changed to reflect that the Project Director reports directly to the Board of Directors regarding the CORE Program. This will be completed 11/1/11.
The Facility Director will meet with the Project Director quarterly to review the CORE goals and marketing plan. The Project Director will report any changes to the Board as they arise. Any CORE activities or changes presented to the Board of Directors will be documented in the monthly Board Minutes which are kept in the CORE Policy and Procedure Manual.
Should the agency require hiring a new Project Director, then the Facility Director will work with the Human Resources Department and Executive Director to ensure that the potential hire meets the qualifications for the Project Director position.
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