INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4, 2019 through November 5, 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, Mid-Atlantic Rehabilitation Services - A.T.P. 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) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to document the name of the person, agency, or organization to whom disclosure would be made to on consent to release information forms in 3 of 14 client records reviewed.
Client # 9 was admitted to the Intake, Evaluation and Referral activity on January 31, 2019 and was discharged on January 31, 2019. The release of information form for an emergency contact was signed and dated by the client on January 31, 2019.
Client # 11 was admitted to the Intake, Evaluation and Referral activity on October 3, 2019 and was discharged on October 3, 2019. A blank release of information form was signed and dated by the client on October 3, 2019.
Client # 12 was admitted to the Intake, Evaluation and Referral activity on August 16, 2019 and was discharged on August 16, 2019. A blank release of information form was signed and dated by the client on August 16, 2019.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Assessment staff will review appropriate completion of Release of Information Forms with Clinical Supervisor by 12/07/2019. Staff will sign form identifying that release of information forms appropriate completion were reviewed. Program coordinators will audit prison assessments for appropriate completion of release of information forms monthly. |
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
The facility failed to document the specific information to be released on consent to release information forms in 1 of 14 client records reviewed.
Client # 11 was admitted to the Intake, Evaluation and Referral activity on October 3, 2019 and was discharged on October 3, 2019. A blank release of information form was signed and dated by the client on October 3, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Assessment staff will review appropriate completion of Release of Information Forms with Clinical Supervisor by 12/07/2019. Staff will sign form identifying that release of information forms appropriate completion were reviewed. Program coordinators will audit prison assessments for appropriate completion of release of information forms monthly. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on release of information forms in four of fourteen client records reviewed.
Client # 9 was admitted to the Intake, Evaluation and Referral activity on January 31, 2019 and was discharged on January 31, 2019. Numerous release of information forms were signed and dated by the client on January 31, 2019 were missing the purpose of disclosure.
Client # 10 was admitted to the Intake, Evaluation and Referral activity on December 12, 2018 and was discharged on December 12, 2018. Numerous release of information forms were signed and dated by the client on December 12, 2018 were missing the purpose of disclosure.
Client # 12 was admitted to the Intake, Evaluation and Referral activity on August 16, 2019 and was discharged on August 16, 2019. Numerous release of information forms were signed and dated by the client on August 16, 2019 were missing the purpose of disclosure.
Client # 14 was admitted to the Intake, Evaluation and Referral activity on June 5, 2019 and was discharged on June 5, 2019. A release of information form to an attorney was signed and dated by the client on June 5, 2019 and was missing the purpose of disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All Assessment staff will review appropriate completion of Release of Information Forms with Clinical Supervisor by 12/07/2019. Staff will sign form identifying that release of information forms appropriate completion were reviewed. Program coordinators will audit prison assessments for appropriate completion of release of information forms monthly. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical 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 in the record.
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Observations
The facility failed to provide documentation verifying that the client had been given written acknowledgement that they were informed that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if that director determines that the information may be detrimental if presented to the client and the reasons for the removal of such sections shall be documented in the record in every client record reviewed.
Client # 1 was admitted to the outpatient activity on May 8, 2019 and was still active at the time of the inspection.
Client # 2 was admitted to the outpatient activity on April 29, 2019 and was still active at the time of the inspection.
Client # 3 was admitted to the outpatient activity on May 28, 2019 and was still active at the time of the inspection.
Client # 4 was admitted to the outpatient activity on August 22, 2019 and was discharged on October 23, 2019.
Client # 5 was admitted to the outpatient activity on January 23, 2019 and was discharged on June 10, 2019.
Client # 6 was admitted to the outpatient activity on February 6, 2019 and was discharged on May 7, 2019.
Client # 7 was admitted to the outpatient activity on February 7, 2019 and was discharged on July 12, 2019.
Client # 8 was admitted to the Intake, Evaluation and Referral activity on February 14, 2019 and was discharged on February 14, 2019.
Client # 9 was admitted to the Intake, Evaluation and Referral activity on January 31, 2019 and was discharged on January 31, 2019.
Client # 10 was admitted to the Intake, Evaluation and Referral activity on December 12, 2018 and was discharged on December 12, 2018.
Client # 11 was admitted to the Intake, Evaluation and Referral activity on October 3, 2019 and was discharged on October 3, 2019.
Client # 12 was admitted to the Intake, Evaluation and Referral activity on August 16, 2019 and was discharged on August 16, 2019.
Client # 13 was admitted to the Intake, Evaluation and Referral activity on June 27, 2019 and was discharged on June 27, 2019.
Client # 14 was admitted to the Intake, Evaluation and Referral activity on June 5, 2019 and was discharged on June 5, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director has updated the MARS Client Handbook to include all clients rights as identified by regulation and included in MARS policy manual. All active clients including clients 1-3 will be given a new handbook by receptionist at their next appointment and sign the form identifying they have been informed of their rights and received their handbook. All clients moving forward will receive the new MARS handbook. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
The facility failed to provide documentation verifying that the client had been given written acknowledgement that they were informed that all clients have the right to appeal, to the director, a decision limiting access to their records in each client record reviewed.
Client # 1 was admitted to the outpatient activity on May 8, 2019 and was still active at the time of the inspection.
Client # 2 was admitted to the outpatient activity on April 29, 2019 and was still active at the time of the inspection.
Client # 3 was admitted to the outpatient activity on May 28, 2019 and was still active at the time of the inspection.
Client # 4 was admitted to the outpatient activity on August 22, 2019 and was discharged on October 23, 2019.
Client # 5 was admitted to the outpatient activity on January 23, 2019 and was discharged on June 10, 2019.
Client # 6 was admitted to the outpatient activity on February 6, 2019 and was discharged on May 7, 2019.
Client # 7 was admitted to the outpatient activity on February 7, 2019 and was discharged on July 12, 2019.
Client # 8 was admitted to the Intake, Evaluation and Referral activity on February 14, 2019 and was discharged on February 14, 2019.
Client # 9 was admitted to the Intake, Evaluation and Referral activity on January 31, 2019 and was discharged on January 31, 2019.
Client # 10 was admitted to the Intake, Evaluation and Referral activity on December 12, 2018 and was discharged on December 12, 2018.
Client # 11 was admitted to the Intake, Evaluation and Referral activity on October 3, 2019 and was discharged on October 3, 2019.
Client # 12 was admitted to the Intake, Evaluation and Referral activity on August 16, 2019 and was discharged on August 16, 2019.
Client # 13 was admitted to the Intake, Evaluation and Referral activity on June 27, 2019 and was discharged on June 27, 2019.
Client # 14 was admitted to the Intake, Evaluation and Referral activity on June 5, 2019 and was discharged on June 5, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director has updated the MARS Client Handbook to include all clients rights as identified by regulation and included in MARS policy manual. All active clients including clients 1-3 will be given a new handbook by receptionist at their next appointment and sign the form identifying they have been informed of their rights and received their handbook. All clients moving forward will receive the new MARS handbook. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
The facility failed to provide documentation verifying that the client had been given written acknowledgement that they were informed that all clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in each client record reviewed.
Client # 1 was admitted to the outpatient activity on May 8, 2019 and was still active at the time of the inspection.
Client # 2 was admitted to the outpatient activity on April 29, 2019 and was still active at the time of the inspection.
Client # 3 was admitted to the outpatient activity on May 28, 2019 and was still active at the time of the inspection.
Client # 4 was admitted to the outpatient activity on August 22, 2019 and was discharged on October 23, 2019.
Client # 5 was admitted to the outpatient activity on January 23, 2019 and was discharged on June 10, 2019.
Client # 6 was admitted to the outpatient activity on February 6, 2019 and was discharged on May 7, 2019.
Client # 7 was admitted to the outpatient activity on February 7, 2019 and was discharged on July 12, 2019.
Client # 8 was admitted to the Intake, Evaluation and Referral activity on February 14, 2019 and was discharged on February 14, 2019.
Client # 9 was admitted to the Intake, Evaluation and Referral activity on January 31, 2019 and was discharged on January 31, 2019.
Client # 10 was admitted to the Intake, Evaluation and Referral activity on December 12, 2018 and was discharged on December 12, 2018.
Client # 11 was admitted to the Intake, Evaluation and Referral activity on October 3, 2019 and was discharged on October 3, 2019.
Client # 12 was admitted to the Intake, Evaluation and Referral activity on August 16, 2019 and was discharged on August 16, 2019.
Client # 13 was admitted to the Intake, Evaluation and Referral activity on June 27, 2019 and was discharged on June 27, 2019.
Client # 14 was admitted to the Intake, Evaluation and Referral activity on June 5, 2019 and was discharged on June 5, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director has updated the MARS Client Handbook to include all clients rights as identified by regulation and included in MARS policy manual. All active clients including clients 1-3 will be given a new handbook by receptionist at their next appointment and sign the form identifying they have been informed of their rights and received their handbook. All clients moving forward will receive the new MARS handbook. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
The facility failed to provide documentation verifying that the client had been given written acknowledgement that they were informed that all clients have the right to submit rebuttal data or memoranda to their own records in each client record reviewed.
Client # 1 was admitted to the outpatient activity on May 8, 2019 and was still active at the time of the inspection.
Client # 2 was admitted to the outpatient activity on April 29, 2019 and was still active at the time of the inspection.
Client # 3 was admitted to the outpatient activity on May 28, 2019 and was still active at the time of the inspection.
Client # 4 was admitted to the outpatient activity on August 22, 2019 and was discharged on October 23, 2019.
Client # 5 was admitted to the outpatient activity on January 23, 2019 and was discharged on June 10, 2019.
Client # 6 was admitted to the outpatient activity on February 6, 2019 and was discharged on May 7, 2019.
Client # 7 was admitted to the outpatient activity on February 7, 2019 and was discharged on July 12, 2019.
Client # 8 was admitted to the Intake, Evaluation and Referral activity on February 14, 2019 and was discharged on February 14, 2019.
Client # 9 was admitted to the Intake, Evaluation and Referral activity on January 31, 2019 and was discharged on January 31, 2019.
Client # 10 was admitted to the Intake, Evaluation and Referral activity on December 12, 2018 and was discharged on December 12, 2018.
Client # 11 was admitted to the Intake, Evaluation and Referral activity on October 3, 2019 and was discharged on October 3, 2019.
Client # 12 was admitted to the Intake, Evaluation and Referral activity on August 16, 2019 and was discharged on August 16, 2019.
Client # 13 was admitted to the Intake, Evaluation and Referral activity on June 27, 2019 and was discharged on June 27, 2019.
Client # 14 was admitted to the Intake, Evaluation and Referral activity on June 5, 2019 and was discharged on June 5, 2019.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director has updated the MARS Client Handbook to include all clients rights as identified by regulation and included in MARS policy manual. All active clients including clients 1-3 will be given a new handbook by receptionist at their next appointment and sign the form identifying they have been informed of their rights and received their handbook. All clients moving forward will receive the new MARS handbook. |
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 provide treatment plan updates within the regulatory timeframe for the outpatient level of care in three of five applicable client records reviewed.
Client #2 was admitted on April 29, 2019 and was active at the time of inspection. The comprehensive treatment plan was completed on June 10, 2019 and an update was due no later than August 10, 2019. However, the update was not completed until September 23, 2019.
Client #3 was admitted on May 28, 2019 and was active at the time of the inspection. A treatment plan update was completed on July 1, 2019 and the next update was due no later than September 1, 2019. However, the update was not completed until September 23, 2019.
Client #7 was admitted on February 7, 2019 and was discharged on July 12, 2019. A treatment plan update was completed on April 3, 2019 and the next update was due no later than June 3, 2019. However, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment Plan in-service was completed during October 2019. Monthly active chart audits will be completed by Quality Improvement staff and results of needed treatment plan update completion will be distributed to clinical supervisors and individual clinicians to ensure completion. Audits will begin by 12/01/2019. |