INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 31, 2016 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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709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to obtain informed and voluntary consent forms for the disclosure of information contained in the client record in ten of ten client records reviewed on October 31, 2016.
Ten client records were reviewed. Ten records required an informed and voluntary consent to release client information. The facility failed to obtain an informed and voluntary consent to release information in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
The consent to release information form states that revocation must be in writing. 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
We will add a line to our Release of Information Form (Consent Form for Disclosure) that will state 'A verbal request to revoke this authorization shall be sufficient for information protected under the drug and alcohol regulations'. We will separate this line out and highlight it so that every person served who falls under Drug and Alcohol regulations knows their rights regarding revocation of consent. The Substance Use Disorder Practice Administrator will be responsible for ensuring this is completed. This will be done by January 1st, 2017 |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
The facility failed to provide documentation of individual training plans in three of eleven personnel/ training records reviewed on October 31 , 2016.
Eleven personnel/training records were reviewed. Individual training plans were required in all eleven personnel/training records. The facility did not document individual training plans for the July 1, 2016-June 30, 2017 training year in personnel records # 6, 7 and 11.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A New Hire training packet is being created so that tracking of DDAP trainings for all employees can be better monitored. Currently, we audit trainings once a year, but that leaves gaps in oversight. With this new process, we will add oversight to ensure that all required staff members are taking the necessary trainings for regulations. The Substance Use Disorder Practice Administrator will be responsible for ensuring that this packet will be in effect by the January 9th, 2017 New Employee Orientation date. |