INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 11-12, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Mercy House of Meadville 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
The facility failed obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven client records.
Seven records were reviewed on March 11-12, 2019. All required documentation of a consent. Client records # 2, 6 and 7 did not document an informed and voluntary consent.
Client # 2 documented a " to whom it may concern " letter dated February 20, 2019. The letter did not identify the person/organization or address of the recipient of the letter. Unable to document that there was a consent to release information for the recipient.
Client# 6 did not document a release of information for the funder.
Client # 7 had a letter dated March 21, 2018. The letter was to a funding agency. The letter documented information that exceeded that which is allowed by 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Faciity director will be responsible for ensuring the following corrective action occur: Clinical Supervisor facilitated a staff training on March 27, 2019 where staff received individual copies of Confidentiality Regulations with particular attention to code 255.5 going over by line item. Clinical Supervisor will require staff to sign a memo that they received training concerning releases, documentation of such and what information is allowable under 255.5. Staff will verbally articulate understanding of confidentiality .
regulations. Facility Director will be given signed training forms to be filed in Mercy House manual. Facility Director or Clincical Supervisor will review the client records for the next 3 months to insure compliance. |
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
The facility failed to ensure the treatment and rehabilitation plans were updated every 60 days in two of seven client records.
Seven client records were reviewed on March 11-12, 2019. Seven records required treatment plan updates. Client records # 1 and 5 documented late updates.
Client # 1 required an update to be completed by November 12, 2018. The update was completed on January 12, 2019.
Client # 5 required an update to be completed by September 10, 2018. The update was completed on October 24, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will be responsible for ensuring the following corrective action is implimented: Clinical Supervisor will facilitate a staff training by April 3, 2019 to retrain staff on 60 day updates on treatment plans, directing that client's who are open but may be incarcerated, or have lapse in treatment require a 60 day update. staff will sign a memo that they received training including a verbal articulation of necessity and requirement of 60 day updates of treatment plan. Facility Director will be given signed training forms to be filed in Mercy House manual. Facility Director or Clincical Supervisor will review the client records for the next 3 months to ensure compliance. |