INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 27-28, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mon Yough Community 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 and a plan of correction is due on October 28, 2010.
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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 the review of client records and an interview with the clinical supervisor, the facility failed to obtain an an informed and voluntary consent from the client for the disclosure of information contained in the client record in two of six client records.
The findings include:
Ten client records were reviewed on September 27-28, 2010. Six client records were reviewed for compliance with obtaining an informed and voluntary consent from the client for the disclosure of information contained in the client record. The facility did not obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 1 and 2.
In client record #1 and 2, urine samples were sent to a laboratory for analysis. There was no documentation that a consent to release information form had been obtained from the client, nor did the facility have a qualified service agreement with the laboratory in place for the release of this information.
An interview with the clinical supervisor on September 28, 2010 confirmed there were no releases of information signed by the above mentioned clients for the laboratory.
An interview with the project director on September 28, 2010, confirmed the facility did not have a qualified service agreement in place with the laboratory.
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Plan of Correction
A qualified service agreement was mailed to the lab on October 15, 2010. Until it is returned and active all patients will sign a consent to release information to the lab. We will contact the lab at least monthly until the agreement is returned. |
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 the review of client records and an interview with the clinical supervisor, the facility failed to document follow up information in four of four client records.
The findings include:
Ten client records were reviewed on September 27-28, 2010. Four client records were required to have follow up information documented. Per facility policy, follow up calls are to be attempted at 3 months. If no contact is made, a second follow up call is attempted at 4 months. If unsuccessful, a follow up survey is mailed. There was no documentation that the follow up contact was made in compliance with the facility's policy is client records # 7, 8, 9 and 10.
Client # 7 was admitted on September 25, 2010 and discharged on April 15, 2010. Follow up documentation provided showed that a follow up survey had been mailed. There was no documentation of when the survey had been mailed, nor was there documentation of attempted follow up calls at the 3rd and 4th month as per facility policy.
Client # 8 was admitted on January 26, 2010 and discharged on April 15, 2010. Follow up documentation provided showed that a follow up survey had been mailed. There was no documentation of when the survey had been mailed, nor was there documentation of attempted follow up calls at the 3rd and 4th month as per facility policy.
Client #9 was admitted on August 9, 2009 and discharged on February 2, 2010. Follow up documentation provided showed that a follow up survey had been mailed. There was no documentation of when the survey had been mailed, nor was there documentation of attempted follow up calls at the 3rd and 4th month as per facility policy.
Client #10 was admitted on October 10, 2009 and discharged on May 12, 2010. Follow up documentation provided showed that a follow up survey had been mailed. There was no documentation of when the survey had been mailed, nor was there documentation of attempted follow up calls at the 3rd and 4th month as per facility policy.
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Plan of Correction
709.93(a)(11)
Reviewed procedure with support staff on 10/6/2010 to include the following information:
All attempts to reach individuals by phone will be documented on the monthly discharge report list to include date phone call was made, who made the call and result of the call.
If the client is unable to be reached by phone, the survey will be mailed. The date the survey is mailed will be indicated on the monthly discharge report and copy of the dated letter will also be placed in the file.
Clinical supervisor or designee will choose 5 DC clients from the report to review that the proper documentation procedure was followed. This will be completed monthly for 3 months and then at least quarterly if we are in compliance with the regulation.
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