INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, RHD Lower Merion Counseling Services 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of five personnel records during the onsite inspection, one record contained documentation of fire extinguisher/fire safety training that was not completed upon employment. Employee # 2 was hired on 4/24/17 but did not complete fire safety training until 7/1/17.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The staff person responsible for new-hire trainings when Employee #2 was hired (QA Coordinator) has left the company. When the deficiency was discovered by the new staff person responsible for new-hire trainings (QA Manager), the training was administered immediately. Going forward, the new QA Manager will ensure that all trainings are administered and completed on time. To do this, the QA Manager is creating a digital training tracking system, which includes due dates, dates of actual trainings, and records of what trainings are necessary and how frequently they must be reviewed. Until this system is complete, the QA Manager is operating within the paper-based system already in place, and using Outlook Calendar to track reminders of when trainings are due for each new hire, with 1 week lead-times. |
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 two client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in one client record. Additionally, one client record had a consent to release information form that was missing required components.
Client #1 was admitted on 3/1/17 and was an active client at the time of inspection. There was a consent to release information form to a funding source, signed on 4/1/17, which did not have include a witness signature, an expiration date or condition of expiration, or the specific information to be disclosed.
Client #2 was admitted on 05/5/16 and was discharged on 8/17/16. The record contained documentation that there were urinalysis tests conducted on 7/28/16 and 6/22/16 and then sent to the urinalysis lab, which identified the client's presence in treatment; however, there was no documented consent to release information form to the lab prior to the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Client #1 was admitted on 3/31/17. This client had a lapse in service but, upon contact, has expressed a desire to return to service. This form will be updated if/when the client returns for services. The cited form, "Payment Authorization" has been amended to include a witness signature, and the following verbiage has been added:
o This form will expire within one year of signing, or upon discharge of the client. This consent may be revoked at any time by written request, or by verbal request if I am physically unable to provide a signature.
The Office Manager has ensured that the revised "Payment Authorization" has been added to the Intake Packet. Additionally, in collaboration, the Office Manager and Clinical Supervisor will continue to ensure that the revised "Payment Authorization" will be completed upon Intake. The Intake Coordinator will ensure, going forward, that the correct form is administered at intake. The staff member who was responsible for this client's intake and documentation has left. On 5/11/2017, all therapists were present at group supervision and they received instruction on the topic of proper administration of Releases of Information. Additionally, LMCS is looking in to having Releases of Information tracked and maintained by our new EHR.
o This form is available digitally upon request.
- Client #2 was admitted 6/8/16. This client was closed at the time of response so nothing can be done to correct this specific incident. On 5/11/2017, all therapists were present at group supervision and they received instruction on the topic of proper administration of Releases of Information. The employee responsible for sending out the lab work has received further, individual instruction on proper documentation of Release of Information. Additionally, LMCS is looking in to having Releases of Information tracked by our new EHR.
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709.30 (1) 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.
(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.
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Observations
Based on a review of two client records, both client records reviewed lacked any documentation verifying the written acknowledgement by clients that they had been notified of each of the client rights, including that facility staff may limit access to their records if determined to be detrimental, reasons for the removal shall the documented, and the right to appeal a decision limiting access to their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- The following wording has been added to intake form, "Rights and Responsibilities," at item 3:
o You have the right to review your records in the presence of a clinician. Facility staff may limit access to records if determined to be detrimental. Reasons for the redaction shall be documented, and you have the right to appeal the decision to limit your access to your record.
The Office Manager has ensured that the revised "Right and Responsibilities" has been added to the Intake Packet. Additionally, in collaboration, the Office Manager and Clinical Supervisor will continue to ensure that the revised "Payment Authorization" will be completed upon Intake. The Intake Coordinator will ensure, going forward, that the correct form is administered at intake.
- This form is available digitally upon request.
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