INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 2-3, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Montgomery County MH/MR Emergency 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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709.123(c) LICENSURE Client records
709.123. Treatment and rehabilitation.
(c) Client records. 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:
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Observations
Based on the review of patient records, the facility failed to document a complete client record to include a record of service and follow-up information, in nine of nine records.
The findings included:
Nine patient records were reviewed during the on-site inspection. All patient records were reviewed for record of service documentation. Four records were discharge records that required follow-up information. The facility failed to document a record of service in client records # 1, 2, 3, 4, 5, 6, 7, 8 and 9. The facility failed to document follow-up information in client records # 7 and 8.
Client # 7 was discharged on 2/6/2014. No follow-up information was documented in the record at the time of the review.
Client # 8 was discharged on 3/6/2014. No follow-up information was documented in the record at the time of the review.
The findings were discussed during the exit interview.
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Plan of Correction
The Utilization Review Department will begin completing the record of service for all patients at MCES with co-occurring disorders. The Performance Improvement Director will monitor completion of this task.
The Medical Records staff is developing a form and procedure for conducting follow-up calls. They will begin making follow-up calls/e-mails to providers, with the patient's written consent, to determine if the patient attended their outpatient appointment. This process will be monitored by the Administrative Assistant. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on observations during the physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings included:
A physical plant inspection was conducted on April 2, 2014, at approximately 10:45 a.m. During the inspection, the group room for the co-occurring patients was observed to have a window in the door. The facility failed to ensure that counseling sessions could not be seen outside the counseling rooms as the window lacked any window treatments and would permit a person outside the group counseling office to view the counseling sessions.
The findings were discussed during the exit interview.
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Plan of Correction
A shade will be installed on the window of the group room. This shade will be closed when there are counseling sessions in progress. The group leader will be responsible for pulling the shade and informing the rounds person of the group attendees. The rounds person will notify the group leader if the shade is not pulled. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on the physical plant inspection, the facility failed to ensure that a portable fire extinguisher was located on each floor.
The findings included:
The physical plant inspection took place on April 2, 2014, at approximately 10:45 a.m. The facility failed to maintain fire extinguishers on each floor as the fire extinguishers were located in a locked housekeeping closet, locked staff offices, locked nurses station and locked stairwell/hallway off of the floor.
The findings were discussed during the exit interview.
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Plan of Correction
A letter was written on 4/14/14 to the Division Director requesting an exception to this standard due to the nature of the patients treated in this facility. The safety officer/ chairperson of the Environment of Care Committee will be responsible to investigate safe alternatives and report them to the Environment of Care Committee on a monthly basis until the exception is approved or compliance with the standard is met. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based upon the review of the facility's fire drill log, the facility failed to set off a fire alarm or smoke detector and failed to evacuate all patients during each fire drill conducted during three of thirteen months reviewed.
The findings included:
The facility's fire drill log for the time period of March 2013 to March 2014 was reviewed.
The facility failed to set off a fire alarm or smoke detector and failed to evacuate all patients during fire drills conducted on March 28, 2013, June 28, 2013 and August 29, 2013. The fire drills documented for those dates occurred during sleeping hours and were identified as "silent alarms."
The findings were reviewed during the exit interview.
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Plan of Correction
A letter was written on 4/14/14 to the Division Director requesting an exception to this standard due to the nature of the patients treated in this facility. The safety officer/ chairperson of the Environment of Care Committee will be responsible to investigate safe alternatives and report them to the Environment of Care Committee on a monthly basis until the exception is approved or compliance with the standard is met. |
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 patient records, the facility failed to ensure that an informed and voluntary consent to release patient information form was obtained in five of nine patient records. Additionally, the facility failed to adhere to the restrictions imposed at 4 Pa Code 255.5 in one of nine patient records.
The findings included:
4 Pa. Code 255.5 (b) states:
(b) Restrictions. Information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Nine patient records were reviewed during the on-site inspection. All patient records were reviewed for documentation of consent to release patient information forms. The facility failed to ensure that an informed and voluntary consent to release patient information form was obtained in records # 1, 2, 3, 5 and 8.
Patient record # 1 did not contain a voluntary and informed consent to release patient information form for the patient's funding source.
Patient record # 2 contained a consent to release patient information form for the patient's funding source that the patient refused to sign. There was no further documentation of obtaining a voluntary and informed consent to release patient information form from the patient for their funding source.
Patient record # 3 did not contain a voluntary and informed consent to release patient information form for the patient's funding source.
Patient record # 5 contained a consent to release patient information form dated 3/28/2014 that did not identify the information to be released or the purpose of the release. Additionally, the consent to release patient information form was not signed by the patient. The record also contained a consent to release patient information form, dated 3/28/2014, for the patient ' s funding source, that was not signed by the patient. A consent to release patient information form for a jail, dated 3/28/2014, identified the information to be released to include the assessment, treatment plan, discharge orders, aftercare plan, discharge summary and progress notes. The information to be released to the jail exceeded the restrictions imposed at 4 Pa Code 255.5(b).
Patient record # 8 did not contain a voluntary and informed consent to release patient information form for the patient's funding source.
The findings were discussed during the inspection and were not disputed.
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Plan of Correction
Clinical staff responsible for obtaining confidential release forms have been reeducated on the need to obtain a release form for the patient's funding source, as well as to properly complete the release forms in their entirety and obtain the patient's signature. If a patient refuses to sign the release form, this should be documented on the release form and multiple attempts will be made to get the patient to sign. Staff also were re-educated on the information to be released to the prison. Medical Records staff to monitor proper completion of release forms and inform their supervisor of any incomplete or incorrect release forms. |
709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on a review of administrative documentation, the facility failed to comply with the Department approved maximum patient capacity for psychiatric hospital services.
The findings included:
The facility's authorized maximum patient capacity for psychiatric hospital services was 2 as of April 3, 2014. The facility reported a psychiatric hospital census of 15 patients on the "Staffing Requirements Facility Summary Report." The facility exceeded its authorized psychiatric hospital capacity by 13 patients on April 3, 2014.
The findings were reviewed and confirmed by the project director.
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Plan of Correction
A letter was submitted to the Pennsylvania Department of Drug and Alcohol Programs requesting an increase from 2 beds to 30 beds. A letter dated April 10, 2014 was received from the Director of the Program Licensure Division approving the increase to 30 beds. The census will be monitored on a daily basis by the Administrative Assistant to ensure that the number of co-occurring patients is not above the 30 beds. If the number is approaching 30, the Crisis Department will be informed so that admissions can be monitored closely. |
709.17(a)(1) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
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Observations
Based on the review of patient records and an interview with the project director, the facility failed to ensure that an unusual incident report was submitted to the Department.
The findings included:
Nine patient records were reviewed during the on-site inspection. One patient record, # 6, included documentation of the patient's death. The project director stated that the patient's death had been reported to the appropriate authorities but confirmed that it was not reported to the Division of Drug and Alcohol Program Licensing. Per Licensing Alert 05-97, Reporting of Unusual Incidents, the facility was required to notify the Division of the patient's death, within 72 hours, via an Unusual Incident Report.
The project director confirmed that the patient's death was not reported to the Department.
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Plan of Correction
The Risk Manager will report identified unusual incidents to the Division of Drug and Alcohol Program Licensure per licensing Alert 05-97 in the appropriate time frames. The administrative senior management team reviews all unusual incidents/events and will monitor the compliance with submission of the appropriate report. |