INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Merakey Delaware County 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) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in two of seven client records reviewed. Client #2 was admitted on June 25, 2021 and was active at the time of inspection. Release of information forms to a primary care physician and an emergency contact were signed by the client on June 25, 2021 that allowed for release of "other" information, but the form did not document the specific information to be disclosed. Client #4 was admitted on February 9, 2021 and was discharged on July 19, 2021. A release of information form from an emergency contact to the facility was signed by the client on February 9, 2021 that allowed for release of "other" information, but the form did not document the specific information to be disclosed. This is a repeat citation from the annual licensing renewal inspection conducted on January 13, 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Medical Records Supervisor will do a training with the intake staff on the proper procedures for completing consents and release of information. This training/re-training will be done with new staff, as well as exiting staff. It will be completed by or before 2/1/22.
Consents and ROIs are done by our business office staff, once the client is with the LOC Assessor, he/she will double check all Consents and ROIs to ensure proper completion during the intake process. If errors are identified, the Assessor will redo the entire consent/ROI with the client.
Additionally, the chart will be audited for correct completion of all consents and release of information by the Intake Supervisor and Medical Records Supervisor as well as checked by the QA Specialist/Internal Clinical Auditor to ensure this citation will not re-occur. Initially these audits will occur weekly for each intake done and then will move to a monthly review, using a checklist that will be submitted to the Clinical Supervisor and Director.
Visual aids will also be completed for staff to have with them as guides while doing Consents and Releases of Information.
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709.28 (c) (4) 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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in two of seven client records reviewed.Client #1 was admitted on September 21, 2021 and was active at the time of inspection. There were release of information forms to an emergency contact and a government agency signed by the witness on September 21, 2021. However, the dated signature of the client was not documented on either consent form. Additionally, there were release of information forms from a primary care physician and government agency to the facility signed by the witness on September 21, 2021. However, the dated signature of the client was not documented on either consent form.Client #7 was admitted on January 6, 2021 and was discharged on June 1, 2021. There was a release of information form to a government agency signed by the witness on January 6, 2021. However, the dated signature of the client was not documented on the consent form.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client charts will be reviewed by the Clinical Supervisor, Medical Records Manager, and Director. If any active charts show incomplete/incorrect consents/ROIs, they will be updated as needed with applicable clients. Medical Records Manager and Clinical Supervisor will complete a final review of ROI/Consents prior to a planned discharge. If any charts show incomplete/incorrect consents/ROIs, they will be updated as needed with applicable client(s) prior to the discharge date.
The Medical Records Manager will also do a training with the intake staff on the proper procedures for completing consents and release of information. This training/re-training will be done with new staff, as well as exiting staff. It will be completed by or before 2/1/22.
Consents and ROIs are done by our business office staff, once the client is with the LOC Assessor, he/she will double check all Consents and ROIs to ensure proper completion during the intake process. If errors are identified, the Assessor will redo the entire consent/ROI with the client.
Additionally, the chart will be audited for correct completion of all consents and release of information by the Intake Supervisor and Medical Records Supervisor as well as checked by the QA Specialist/Internal Clinical Auditor to ensure this citation will not re-occur. Initially these audits will occur weekly for each intake done and then will move to a monthly review, using a checklist that will be submitted to the Clinical Supervisor and Director.
Visual aids will also be completed for staff to have with them as guides while doing Consents and Releases of Information.
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709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of a witness on release of information forms in two of seven client records reviewed.Client #5 was admitted on October 22, 2020 and was discharged on July 13, 2021. There was a release of information form from an emergency contact to the facility signed by the client on October 22, 2020. However, the dated signature of a witness was not documented on the consent form.Client #6 was admitted on September 15, 2020 and was discharged on April 9, 2021. There were release of information forms to a government agency and an emergency contact signed by the client on September 15, 2020. However, the dated signature of a witness was not documented on either consent form. Additionally, there was a release of information form from a primary care physician to the facility signed by the client on September 15, 2020. However, the dated signature of the witness was not documented on the consent form.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Medical Records Supervisor will do a training with the intake staff on the proper procedures for completing consents and release of information. This training/re-training will be done with new staff, as well as exiting staff. It will be completed by or before 2/1/22.
Consents and ROIs are done by our business office staff, once the client is with the LOC Assessor, he/she will double check all Consents and ROIs to ensure proper completion during the intake process. If errors are identified, the Assessor will redo the entire consent/ROI with the client.
Additionally, the chart will be audited for correct completion of all consents and release of information by the Intake Supervisor and Medical Records Supervisor as well as checked by the QA Specialist/Internal Clinical Auditor to ensure this citation will not re-occur. Initially these audits will occur weekly for each intake done and then will move to a monthly review, using a checklist that will be submitted to the Clinical Supervisor and Director.
Visual aids will also be completed for staff to have with them as guides while doing Consents and Releases of Information.
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709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include case consultation notes, in two of six applicable client records reviewed.Client #6 was admitted on September 15, 2020 and was discharged on April 9, 2021. Client #7 was admitted on January 6, 2021 and was discharged on June 1, 2021.This is a repeat citation from the annual licensing renewal inspection conducted on January 13, 2021.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will do a training with the counselors on the proper time frames that a case conference must be completed. This will occur by or before 2/1/22.
The Clinical Supervisor has created a case conference grid, but also will check the case conferences done during supervision and review with each counselor on an ongoing basis.
The QA Specialist/Internal Clinical Auditor will also spot check the case conferences during the monthly conducted audit to ensure this deficiency does not re-occur.
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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 a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include aftercare plans, in one of three applicable client records reviewed.Client #7 was admitted on January 6, 2021 and was discharged on June 1, 2021.This is a repeat citation from the annual licensing renewal inspection conducted on January 13, 2021.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will do a training with the counselors on the times that an aftercare plan must be completed.
This will occur by or before 2/1/22.
The Clinical Supervisor will review/spot check every month all new clients that are due for an aftercare plan, specifically that all are done as required through using the Avatar system and will confirm the completeness of the aftercare plans during Supervision.
The QA Specialist/Internal Clinical Auditor will also spot check the aftercare plans during the monthly conducted audit to ensure this deficiency does not re-occur.
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