INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 3-4, 2016 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:
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Plan of Correction
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
The facility failed to ensure that electronic record were stored on secure, password protected data base.
Client records reviewed during the October 3-4, 2016 licensing inspection were computerized records. In reviewing the drug and alcohol clients, it was noted that the mental health information could be accessed as well. The facility director was interviewed and stated that mental health staff had access to drug and alcohol client records. There was no separate, secure and password protected data base.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To maintain confidentiality standards pertaining to Chapter 709.28 (b), all Drug and Alcohol client information will be locked down using On-screen Security and D&A Only versions of shared documents will be created using the Row Based Security feature within the EMR restricting access of records to non-D&A program staff. Any additional support staff requiring access to the D&A record will be added to the Program rooster and will receive required DDAP trainings within 365 days.
The above security features were tested by Program staff and IT staff on October 31, 2016 and were found to be compliant with Chapter 709.28 (b). The agency IT Department will ensure that security features are fully activated within the EMR by 12/2/2016.
The program Supervisor in collaboration with the department Practice Supervisor will ensure that any additional support staff requiring access to the D&A record will be added to the Program roster and receive DDAP required trainings within 365 days.
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709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
The facility failed to provide counseling to a client on a regular and scheduled basis including individual counseling, at least twice weekly in three of the four records reviewed on October 3-4, 2016.
Ten client records were reviewed. Four records were reviewed as partial hospitalization records. Client records # 2, 5 and 6 did not receive individual counseling at least twice weekly.
Client # 2 was admitted on 6/9/16. The client did not receive two individual counseling session for the weeks of July 24 and 31, 2016.
Client # 5 was admitted on 1/19/16. The client did not receive two individual counseling session for the weeks of February 14 and 20, 2016.
Client # 6 was admitted on 8/24/16. The client did not receive two individual counseling session for the weeks of August 28, September 5, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinicians received training from the program Supervisor on 10-5-16 pertaining to Chapter 709.82(d)(1). Clinicians were instructed to immediately, as of 10/05/2016 begin scheduling individual sessions twice weekly for PHP clients using the tentative transaction scheduler in the agency EMR. This process will ensure that clients are scheduled for individual sessions twice weekly in advance and are consistently attending sessions twice weekly as per DDAP regulations.
The program Supervisor reviewed clinician schedules for compliance and will continue to perform monthly audits of D&A records as per the MYCS Compliance Policy to ensure that individual sessions are continuing to be scheduled twice weekly for PHP clients.
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