INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist. 2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 26, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.Based on the findings of Part 2, an abbreviated 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) 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.
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Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in two of seven client records reviewed on October 26, 2020.The facility obtained prior authorization from the funding entity for drug and alcohol services during the intake process without written consent from the client in the following records.Client # 1 was admitted June 4, 2020.Client # 4 was admitted December 6, 2019 and discharged March 11, 2020.The findings were reviewed with staff during the licensing process.
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Plan of Correction
The Fiscal Manager who oversees registration clerks as part of the central office team has reviewed the requirement to obtain written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record for authorization from the funding entity for drug and alcohol services during the intake process as of 12/01/2020.
Clinical supervisors and utilization review managers will monitor that consents are completed during chart monitoring and when obtaining authorizations prior to release of information required to have consents completed to ensure they are accurate and up-to-date. Results will be shared and used in clinical supervision with staff on an on-going basis beginning 12/01/2020. The Clinician will ensure a consent is obtained for the funding entity for client #1 open record. |
709.30 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.
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Observations
Based on a review of client records, 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 on October 26, 2020.There was no documentation that clients were informed of the following rights: the right to retain civil rights and liberties except as provided by statute and the right to not be discriminated against on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.Client # 1 was admitted June 4, 2020.Client # 2 was admitted December 11, 2019.Client # 3 was admitted November 25, 2019 and discharged June 24, 2020.Client # 4 was admitted December 6, 2019 and discharged March 11, 2020.Client # 5 was admitted September 16, 2019.Client # 6 was admitted October 28, 2019 and discharged February 6, 2020.Client # 7 was admitted October 28, 2019 and discharged February 6, 2020.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
§ 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.
Clinical supervisors will train staff on the requirement of written policies and procedures on client rights and how to document written acknowledgement by clients that they have been notified of those rights.
The Bills of Rights will be an independent document that has all of the following client 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. (2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. (3) Clients have the right to inspect their own records. 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. (4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. (6) Clients have the right to submit rebuttal data or memoranda to their own records.
28 Pa. Code § 709.30
The Bill of Rights document will be reviewed with the client upon admission to the program. The client will provide a signature that they understand their rights and were given a copy. For records of those clients listed in this POC, the Bill of Rights shall be reviewed and signature obtained of their understanding and receipt of the Bill of Rights.
Training of staff on this process will be completed by December 31, 2020. Clinical Supervisors will conduct monthly documented internal audits of client records to verify that clients are understanding and getting a copy of the Bills of Rights.
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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
Based on a review of client records, the facility failed to document the review and update of treatment and rehabilitation plans at least every 60 days in three of seven client records reviewed on October 26, 2020.Client # 1 was admitted June 4, 2020. The individual treatment plan was completed July 16, 2020. No updates were documented.Client # 2 was admitted December 11, 2019. The individual treatment plan was completed April 7, 2020. No updates were documented until August 19, 2020.Client # 3 was admitted November 25, 2019 and discharged June 24, 2020. The individual treatment plan was completed December 2, 2019. No updates were documented.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
709.92. Treatment and rehabilitation services. (b) 709.92. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
Clinical supervisors will train staff on the requirement of treatment and rehabilitation plans shall be reviewed and updated at least every 60 days, along with providing a tracking tool to be used to record due dates of treatment and rehabilitation plan due dates. This training will be completed by December 31, 2020 and documented in clinical supervision notes, and repeated for new hires on-going.
Clinical supervisors will monitor the due dates of treatment and rehabilitation plans by using a report from the electronic health report. The report information will be shared and used in clinical supervision with staff that who are responsible for creating treatment and rehabilitation plans with clients. Treatment rehabilitation plans that were not completed for the clients listed in the POC and are still admitted will be completed.
Clinical Supervisors will conduct monthly documented internal audits of client records to verify treatment and rehabilitation plans are reviewed and updated at least every 60 days.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a complete client record including case consultation notes every 90 days, per facility policy, in three of seven client records reviewed on October 26, 2020.No case consultation notes were documented in the following client records.Client # 1 was admitted June 4, 2020.Client # 2 was admitted December 11, 2019. Client # 3 was admitted November 25, 2019 and discharged June 24, 2020. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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: (8) Case Consultation notes completed every 90 days.
Clinical supervisors will train staff on the requirement of case consultations should be conducted at least every 90 days, along with providing a tracking tool to be used to record case consultation due dates. This training will be completed by December 31, 2020 and documented in clinical supervision notes, and repeated for new hires on-going. Case Consultations not completed in the list of clients in the POC will be completed.
Clinical supervisors will monitor that case consultations are conducted every 90 days by review of charts in the electronic health report on a monthly basis. Results will be shared and used in clinical supervision with staff that who are responsible for conducting case consultation.
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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 a review of client records, the facility failed to document a complete client record including follow-up information within 30 days of discharge, per facility policy, in two of three client records reviewed on October 26, 2020.No follow-up information was documented in the following client records.Client # 6 was admitted October 28, 2019 and discharged February 6, 2020.Client # 7 was admitted October 28, 2019 and discharged February 6, 2020.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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 within 30 days of discharge. Clinical supervisors will train clinicians on the requirement of Follow-up information within 30 days of discharge, along with providing a tracking tool to be used to record Follow-up information due dates. This training will be completed by December 31, 2020 and documented in clinical supervision notes, and repeated for new hires on-going. Follow-up that were not completed for the clients in the POC list with get a Follow-up completed.Clinical supervisors will monitor that Follow-up information is conducted 30-day post-discharge by review of charts in the electronic health report on a monthly basis. Results will be shared and used in clinical supervision with clinicians who are responsible for conducting case consultation. |