INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Mercy Behavioral Health 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of staff training records, the facility failed to document TB/STD training in one of three records reviewed on June 2, 2021.
Employee # 10 was hired for the position of counselor on March 4, 2019. No documentation of TB/STD training was provided for employee # 10.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director will have employee number 10 register for TB/STD training within the next 30 days. Facility Director will follow-up with all supervisors monthly to ensure that new staff is able to register and complete the required trainings within the first year of employment. All required trainings will be documented on annual training plan. Trainings will be recorded on training log when they are complete. The facility will be in compliance by July, 31, 2021. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of staff training records, the facility failed to document 25 clock hours of training required for counselors in one of two records reviewed on June 2, 2021.
Employee # 8 was hired for the position of counselor on August 17, 1997. The facility's training year was reviewed for July 1, 2019 through June 30, 2020. Only 12 clock hours of annual training was documented for employee # 8.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director will meet with staff monthly to ensure that all counselors are meeting the requirements for 25 clock hours of training annually. The facility director will ensure that all staff are able to meet the requirements before the annual training log is due so that this deficiency does not recur. This plan will be implemented and the facility will be in compliance by July 31, 2021. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the April 2020 through April 2021 monthly fire drill records, the facility failed to document an unannounced fire drill for April 2021.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director attained the fire drill log for April 2021 after the audit was complete. To ensure that this deficiency does not recur, the facility director will ensure that fire drill log is kept up to date and request all fire drill records throughout the year quarterly. The facility was in compliance on June 14, 2021. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of personnel records, the facility failed to document annual performance evaluations in four of four personnel records reviewed on June 2, 2021.
No annual performance evaluations were completed in 2020 for the following employees.
Employee # 1 was hired February 16, 2015.
Employee # 3 was hired May 23, 2005.
Employee # 8 was hired May 17, 1997.
Employee # 9 was hired February 18, 2019.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility director will complete performance evaluations annually. The facility director completed performance evaluations for all staff in April 2021. Performance evaluations will be completed in April 2022. The facility will be in compliance by 7/31/2021 |
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.
|
Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in six of seven client records reviewed on June 2, 2021.
The facility obtained authorization from the funding entity for drug and alcohol services during the intake process and billed for services without written consent from the client in the following records.
Client # 1 was admitted January 14, 2021.
Client # 3 was admitted June 10, 2020 and discharged April 22, 2021.
Client # 4 was admitted January 22, 2021 and discharged April 5, 2021.
Client # 5 was admitted December 31, 2020 and discharged February 8, 2021.
Client # 6 was admitted July 21, 2020 and discharged March 10, 2021.
Client # 7 was admitted March 25, 2021.
The findings were reviewed with staff during the licensing process.
This is a repeat citation from the October 26, 2020 licensing inspection.
|
Plan of Correction
On June 3, 2021, facility director communicated with fiscal manager who oversees registration clerks as part of the central office team regarding the requirements to obtain written, informed, and voluntary consent from client prior to the discloser of information contained in the client record for authorization from the funding entity during the intake process. This was a follow-up from the previous plan of correction.
Clinical supervisors, counselors, and utilization review managers will monitor that consents are completed during chart monitoring. They will monitor that when authorizations are obtained prior to release of information that they are accurate and up-to-date. Results will be shared with staff during clinical supervision on an ongoing bases beginning 7/31/2021. Funding consents will be obtained for client #1 and client #7 whose records remain open.
The facility director will have on-going communication with front desk staff during monthly meeting to verify that these consents are being obtained at time of admission during the registration process. Facility will be in compliance by 7/31/2021. |
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).
|
Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the dated signature of the client in three of seven client records reviewed on June 2, 2021.
Consents were documented during the intake process in the following client records.
Client # 2 was admitted March 18, 2021. A consent for parole did not include the dated signature of the client.
Client # 4 was admitted January 22, 2021 and discharged April 5, 2021. A consent for a government agency did not include the dated signature of the client.
Client # 5 was admitted December 31, 2020 and discharged February 8, 2021. A consent for a treatment provider did not include the dated signature of the client.
The findings were reviewed with staff during the licensing process.
|
Plan of Correction
The facility director will contact information technology Manager who oversees the electronic health record to have a signature date added into the electronic consents.
The facility director and clinical supervisor will instruct all staff that all consents must by signed beginning 7/12/2021 when all staff is required to work onsite. All consent will be signed by the client on a paper consent to be scanned in to the electronic health record, once the change is made to the electronic health record to include the date with the signature all consents will be completed with signature and date electronically.
The facility director and clinical supervisors will monitor charts on a monthly basis reviewing consents to ensure that all consents have a signature and signature date.
The changes to the consents in the electronic health record will be requested by 7/31/2021. The facility will be in compliance by 7/31/2021. |
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.
|
Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client that included the dated signature of the witness in three of seven client records reviewed on June 2, 2021.
Consents were documented during the intake process in the following client records.
Client # 2 was admitted March 18, 2021. A consent for parole did not include the date the witness signed the document.
Client # 4 was admitted January 22, 2021 and discharged April 5, 2021. A consent for a government agency did not include the date the witness signed the document.
Client # 5 was admitted December 31, 2020 and discharged February 8, 2021. A consent for a treatment provider did not include the date the witness signed the document.
The findings were reviewed with staff during the licensing process.
|
Plan of Correction
The facility director will contact information technology Manager who oversees the electronic health record to have a signature date added into the electronic consents for the witness and the client.
The facility director and clinical supervisors will monitor charts on a monthly basis reviewing consents to ensure that all consents have a signature date for the witness and for the client.
The changes to the consents in the electronic health record will be requested by 7/31/2021. The facility will be in compliance by 7/31/2021. |
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.
|
Observations
Based on a review of client records, the facility failed to document the review and update of treatment and rehabilitation plans at least every 60 days in four of four client records reviewed on June 2, 2021.
Client # 1 was admitted January 14, 2021. The individual treatment plan was documented January 18, 2021. No treatment plan updates were documented.
Client # 2 was admitted March 18, 2021. The individual treatment plan was documented March 28, 2021. No treatment plan updates were documented.
Client # 3 was admitted June 10, 2020 and discharged April 22, 2021. No treatment plan updates were documented since September 18, 2020.
Client # 6 was admitted July 21, 2020 and discharged March 10, 2021. No treatment plan updates were documented since December 1, 2020.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 7 - 8, 2019 and October 26, 2020 licensing inspections.
|
Plan of Correction
The facility director and clinical supervisor will meet with counselors monthly during supervision to review treatment plans and caseloads. Facility director and clinical supervisor will ensure that all staff is completing treatment plan updates at least every 60 days for active clients.
If a client is inactive in treatment the counselor will follow discharge procedure. Facility director will monitor completion of discharges and treatment plans by running a monthly report.
Facility director and clinical supervisor will review all treatment plan requirements with staff including that treatment plans must be updated at least every 60 days. These protocols will be implemented and the facility will be in compliance by 7/31/2021. |
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.
|
Observations
Based on a review of client records, the facility failed to document a complete client record including case consultation notes every 90 days, per facility policy, in three of three client records reviewed on June 2, 2021.
No case consultation notes were documented in the following client records.
Client # 1 was admitted January 14, 2021.
Client # 3 was admitted June 10, 2020 and discharged April 22, 2021.
Client # 6 was admitted July 21, 2020 and discharged March 10, 2021.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 26, 2020 licensing inspection.
|
Plan of Correction
The facility director and the clinical supervisor will review the process of documenting case consultation in the electronic health record with all staff. Staff will review the policy that all case consults are completed every 90 days and at LOC change. Staff will be adequately training on the purpose of case consults and how to complete case consults in the the electronic health record.
Facility director and clinical supervisor will monitor the completion of case consults through monthly chart audits. These chart audits will be reviewed with staff during supervision. This process will ensure that this deficiency does not recur. This protocol will be implemented and the facility will be in compliance by 7/31/2021. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to document a complete client record including follow-up information within 30 days of discharge, per facility policy, in four of four client records reviewed on June 2, 2021.
No follow-up information was documented in the following client records.
Client # 3 was admitted June 10, 2020 and discharged April 22, 2021.
Client # 4 was admitted January 22, 2021 and discharged April 5, 2021.
Client # 5 was admitted December 31, 2020 and discharged February 8, 2021.
Client # 6 was admitted July 21, 2020 and discharged March 10, 2021.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the October 26, 2020 licensing inspection.
|
Plan of Correction
Facility director and clinical supervisor re-trained staff on the discharge follow-up policy and procedure in April 2021. Beginning in May 2021 all discharge follow-ups have been completed.
Facility director and clinical supervisor will continue to monitor that these are completed through monthly chart reviews and clinical supervision.
Discharges are monitored on a spreadsheet where the 30 day follow-up call is documented. The 30 day follow-up is documented in the electronic health record. The facility director will ensure that this process continues to be followed and that this deficiency does not recur, facility will be in compliance by 7/31/2021. |