INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 4, 2026 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Montgomery County MH/MR Emergency Service, 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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709.28 (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 client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in one of seven client records reviewed.Client # 7 was admitted on October 8, 2025 and was discharged on October 15, 2026. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.This is a repeat citation from the January, 25, 2024 and February 20, 2025 annual licensing renewal inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Support Services Director/Compliance Officer discussed the results of the DDAP survey at the monthly meeting of Performance Improvement Committee on 3/17/2026. The Committee consists of all clinical supervisors. A follow-up memo was issued to all clinical supervisors on 03/31/2026 regarding the requirement for ROI completion and the monitoring process. The memo including the following information to address the citation:
- Clarification of the four categories required to have a completed and signed ROI being the PCP, family, provider and insurance.
- Crisis Workers are to document in the pre-established section of the Contact Sheet the status of the four required ROIs on admission.
- Information Systems populated the pre-established section of the Contact Sheet containing the information regarding the ROIs into the social service notes. The goal is to assist the caseworker with determining the ROIs completed/signed on admission and the ROIs that still need to be completed/signed.
- All charts will be reviewed by the Administrative Support Services Director/Compliance Officer or designee after admission to determine what ROIs were completed and what ROIs are still needed.
- The Administrative Support Services Director/Compliance Officer or designee will notify the supervisor of any missing, inaccurate or incomplete ROIs. The supervisor is expected to address the issue(s) directly with the appropriate employee and notify the Administrative Support Services Director/Compliance Officer or designee of the resolution.
- Any ROI issues that are not resolved with the supervisor will be addressed with the CEO and/or Medical Director.
- The Performance Improvement Department will continue to monitor the charts throughout the remainder of the patient's stay for appropriate completion of additional ROIs.
- Data and findings will be discussed at the Performance Improvement monthly committee meetings.
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709.17(a)(3) 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:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for not completing an informed and voluntary consent to release information form prior to the disclosure of information was submitted and approved by the Department for the January 25, 2024 and February 20, 2025 annual licensing inspections. Failing to complete a release of information form prior to the disclosure of information was again found to be a deficiency in the March 4, 2026 licensing inspection. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All plans of correction (POC) will be incorporated into the agenda for the monthly Performance Improvement Committee meetings in order to monitor data, ensure compliance and discuss any action(s) that need to be taken related to the POC. If there are changes to policies and/or procedures regarding the POC, appropriate supervisors will be required to provide written instructions to their staff regarding the changes. Supervisors will also be responsible to address any non-compliance issues with identified staff following the hospital's Corrective Counseling Policy. The CEO will ultimately be responsible for the POC and ensuring adherence. If it is determined that a department is not adhering to the policies/procedures related to the POC, the appropriate supervisor will meet with the CEO and Medical Director to address the non-compliance and develop a plan to ensure long-term compliance. Ongoing non-compliance by a department may result in the CEO and/or Medical Director utilizing the Corrective Counseling Policy for the supervisor. |