INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 30-October 2, 2008 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 and a plan of correction is due on November 4, 2008.
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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 the review of seven personnel records, the facility failed to document that staff was instructed in the use of the fire extinguisher upon staff employment in three of seven records where required.
Findings:
There was no documentation in the personnel records that the employee had been instructed in the use of the fire extinguisher upon employment in records # 4, 5 and 6. The training was late in client record #3.
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Plan of Correction
P271
705.28 Fire Safety. Fire Extinguisher training.
- All staff are trained no later than seven days from the date of employment in the use of fire extinguishers. The training manager of MYCS creates a certificate which documents such and it is then placed in the employee training binder. This process will be reviewed by the clinical supervisor and confirmed with the training manager. This correction will be in place by 1/1/09.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of seven personnel records, the facility failed to document that all staff on all shifts were trained to perform assigned tasks during emergencies in three of seven client records where required.
Findings:
There was no documentation in the personnel records that the employee had been trained to perform assigned tasks during an emergency in client records # 4, 5 and 6. The training was late in client record #3.
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Plan of Correction
P277
705.28 Fire Safety. Fire Drills
- All staff will be trained by the clinical supervisor no later than seven days from the date of employment to perform assigned tasks during emergencies via review of MYCS and department specific emergency policy and procedure. This will be documented on the staff training plan. This correction will be in place by 1/1/09.
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709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based on the review of seven personnel records, the facility failed to document that the employee had the right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the client records in five of seven records where required.
Findings:
There was no documentation in the personnel records that the employee was informed of this right in client records # 3, 4, 5, 6 and 7.
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Plan of Correction
0237
709.26 Personnel management. (e) The project director shall develop written policies on employee rights and demonstrate the project's efforts toward informing staff of the following: (2) The employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
- The current MYCS employee handbook which human resources staff reviews on the first day of hire (all staff have access to the handbook via MYCS Sharepoint) currently states: "A staff member may request to review their records". The facility director will ask the Sr. Mgmt team at MYCS to approve a revision to the MYCS employee handbook, section personnel records as such: "A staff member has the right to review their records, request the correction or removal of inaccurate, irrelevant, outdated or incomplete information and to submit rebuttal data or memoranda to his own record." This correction will be in place by 1/1/09.
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709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
Based on the review of seven personnel records, the facility failed to document that the employee had the right to submit rebuttal data or memoranda to his own records in five of seven records where required.
Findings:
There was no documentation in the personnel records that the employee was informed of this right in client records # 3, 4, 5, 6 and 7.
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Plan of Correction
0239
709.26. Personnel management. (e) The project director shall develop written policies on employee rights and demonstrate the project's efforts toward informing staff of the following: (3) The employee's right to submit rebuttal data or memoranda to his own records.
- The current MYCS employee handbook which human resources staff reviews on the first day of hire (all staff have access to the handbook via MYCS Sharepoint) currently states: "A staff member may request to review their records". The facility director will ask the Sr. Mgmt team at MYCS to approve a revision to the MYCS employee handbook, section personnel records as such: "A staff member has the right to review their records, request the correction or removal of inaccurate, irrelevant, outdated or incomplete information and to submit rebuttal data or memoranda to his own record." This correction will be in place by 1/1/09.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on the review of eight client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client records in eight of eight client records where required.
Findings:
The consent forms indicated that the revocation of the consent must be in writing. The consent forms did not inform the client that the consent could also be revoked orally in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
0277
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:
- The medical record department has a form (referred to on the Authorization for Release of Protected Health Information) which states you can revoke a consent orally. The paper process is in place to maintain proper workflow within the medical records department. The facility director will edit the current Drug and Alcohol Services Client Bill of Rights to include a statement regarding the right to revoke a consent orally as it relates to your client record. This correction will be in place by 1/1/09.
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709.30(3) LICENSURE Client Rights
709.30. Client rights.
(3) A client has the right to inspect his own records. The project 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 and kept on file.
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Observations
Based on the review of eight client records, the facility failed to document in eight of eight client records where required, that the client was informed that the project 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.
Findings:
This right was not documented on the client's right sign off sheets documented in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
0303
709.30. Client rights. (3) A client has the right to inspect his own records. The project 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 and kept on file.
- The facility director will edit the Confidentiality policy: project director and not the quality assurance/risk manager may temporarily remove portions of the record... This correction will be in place by 1/1/09
- Facility director will edit the Drug and Alcohol Services Client Bill of Rights to include a statement regarding the project directors ability to temporarily remove portions of the record prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. This correction will be in place by 1/1/09.
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709.30(4) LICENSURE Client Rights
709.30. Client rights.
(4) The client has the right to appeal a decision limiting access to his records to the project director.
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Observations
Based on the review of eight client records, the facility failed to document that the client was informed of the right to appeal a decision limiting access to his records to the project director.
Findings:
This right was not documented on the client's right sign off sheets document in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
0305
709.30. Client rights. (4) The client has the right to appeal a decision limiting access to his records to the project director.
- The facility director will edit the Confidentiality policy: project director and not the quality assurance/risk manager received appeals regarding a decision limiting access to their record. This correction will be in place by 1/1/09.
- The facility director will edit the Drug and Alcohol Services Client Bill of Rights to include a statement informing clients of their right to appeal a decision limiting access to their records to the project director. This correction will be in place by 1/1/09.
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709.30(5) LICENSURE Client Rights
709.30. Client rights.
(5) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
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Observations
Based on the review of eight client records, the facility failed to document that the client was informed of the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
Findings:
This right was not documented on the client right sign off sheet documented in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
0307
709.30. Client rights. (5) The client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records.
- The facility director will edit the Confidentiality policy: remove the requirement of submission to the quality assurance/risk manager when a client requests the correction of inaccurate, irrelevant, outdated or incomplete information from his records. This correction will be in place by 1/1/09.
- The facility director will edit the Drug and Alcohol Services Client Bill of Rights to include a statement informing clients of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information from his records to the project director. This correction will be in place by 1/1/09.
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709.30(6) LICENSURE Client Rights
709.30. Client rights.
(6) The client has the right to submit rebuttal data or memoranda to his own records.
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Observations
Based on the review of eight client records, the facility failed to document that the client was informed of the right to submit rebuttal data or memoranda to his own records.
Findings:
This right was not documented on the client right sign off sheets documented in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
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Plan of Correction
0309
709.30. Client rights. (6) The client has the right to submit rebuttal data or memoranda to his own records.
- The facility director will edit the Drug and Alcohol Services Client Bill of Rights to include a statement informing clients of their right to submit rebuttal data or memoranda to their own record. This correction will be in place by 1/1/09.
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709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of eight client records on September 30- October 2, the facility failed to document an aftercare plan in one of one client record where required.
Findings:
There was no aftercare plan documented in client record #8.
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Plan of Correction
1907
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: (9) Aftercare plan, if applicable.
- The utilization review coordinator will training staff on the use of the afterare plan. The facility director will review the policy & procedure with staff. This correction will be in place by 1/1/09
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