INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 24, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Penndel Mental Health Center 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to provide documentation that the individual training plan was developed with input from both the employee and the supervisor in one of three client records reviewed. Employee #2 was hired as a lead counselor on October 4, 2021. The individual training plan was not signed by the employee or supervisor and there was no other documentation provided indicating the plan was developed with input from both the supervisor and the employee.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee and supervisor in question of this citing hadn't signed the individual training plan. Future training plans will be discussed and co-signed by the supervisee and supervisor.
Director will monitor that all training plans are completed and signed by both parties the one in question has been signed and placed in employee's supervision folder.
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the July 2021 through April 2022 fire drill logs, the facility failed to identify, on the fire drill log, which exit route was used during every fire drill conducted.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC form has been amended to show written fire drill record of the exit route used.
Director has instructed facility director to correct the fire drill record to meet the requirements requested through the DDAP audit. New form has been uploaded into the S drive PHMC forms.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on an administrative review of the policy and procedure manual, the facility failed to document that the project director had prepared, annually updated, and signed the facility's written manual, which delineates the project policies and procedures. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Policy and procedure manual needs a signed copy that the director has reviewed and updated any changes.
Director has already signed and placed the form to meet the requirements requested.
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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 obtain an informed and voluntary consent form from the client for the disclosure of information contained in the client record in six of seven records reviewed.Client #1 was admitted on January 31, 2022 and was active at the time of inspection. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information. Client #2 was admitted on March 4, 2022 and was active at the time of inspection. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information. Client #3 was admitted on February 28, 2022 and was active at the time of inspection. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information. Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information. Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information. Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022. There was documentation of billing to the funding source; however, there was no consent form documented in the record prior to the disclosure of information. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC clinicians were instructed to state the purpose of the ROI form and offer the client the right to accept or refuse a copy of the form. All forms will be signed by the client's and until a new EMR is up and running they will be scanned and uploaded to Profiler.
Director will audit client charts to monitor the ROI throughout the year. All ROI forms will be reviewed by the Clinical Director after initial intake and scanned and uploaded to Profiler until the new EMR is up and running.
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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 forms in four of seven client records reviewed. Client #2 was admitted on March 4, 2022 and was active at the time of inspection. A release of information form to a social services center, dated May 12, 2022, did not document the specific information to be disclosed.Client #3 was admitted on February 28, 2022 and was active at the time of inspection. Release of information forms to an emergency contact and an attorney, both signed and dated by the client on August 5, 2021, did not document the specific information to be disclosed.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021. A release of information form to a public defender, signed and dated by the client on February 22, 2021, did not document the specific information to be disclosed.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022. A release of information form to an emergency contact, signed and dated by the client on November 12, 2021, did not document the specific information to be disclosed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC clinicians were instructed to state the purpose of the ROI consent form, by discussing with the client the nature of the release and what can/can't be released to a third party by checking the appropriate boxes on the consent form then offer the client the right to accept or refuse a copy of the ROI consent form. All forms will be signed by the client's and until a new EMR is up and running they will be scanned and uploaded to Profiler.
Current clients will be given the new ROI consents designating exactly what can be disclosed to a third party.
Director will audit client charts to monitor the ROI throughout the year. All ROI forms will be reviewed by the Clinical Director after initial intake and scanned and uploaded to Profiler until the new EMR is up and running.
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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
Based on a review of client records, the facility failed to document the purpose of a disclosure on consent forms in four of seven client records reviewed. Client #2 was admitted on March 4, 2022 and was active at the time of inspection. A release of information form to an emergency contact, dated May 2, 2022, did not document the purpose of the disclosure. Client #3 was admitted on February 28, 2022 and was active at the time of inspection. Release of information forms to an emergency contact and an attorney, both signed and dated by the client on August 5, 2021, did not document the purpose of the disclosures.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021. A release of information form to a public defender, signed and dated by the client on February 22, 2021, did not document the purpose of the disclosure. Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022. A release of information form to an emergency contact, signed and dated by the client on November 12, 2021, did not document the purpose of the disclosure. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC clinicians were instructed to state the purpose of the ROI form and offer the client the right to accept or refuse a copy of the form. All forms will be signed by the client's and until a new EMR is up and running they will be scanned and uploaded to Profiler.
Director will audit client charts to monitor the ROI throughout the year. All ROI forms will be reviewed by the Clinical Director after initial intake and scanned and uploaded to Profiler until the new EMR is up and running.
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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 one of seven client records reviewed.Client #2 was admitted on March 4, 2022 and was active at the time of inspection. There was a release of information form to an emergency contact; however, the dated signature of the client was not documented.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC clinicians were instructed to have clients sign and date all of the ROI consent forms. All forms will be signed by the client's, reviewed by the clinical director, and until a new EMR is up and running they will be scanned and uploaded to Profiler.
Clients signature, date, and accepted/refused document has been added to the new ROI consents. Director will review forms before they are scanned ensuring that all of the above was obtained.
Director will audit client charts to monitor the ROI throughout the year. All ROI forms will be reviewed by the Clinical Director after initial intake and scanned and uploaded to Profiler until the new EMR is up and running.
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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 one of seven client records reviewed.Client #2 was admitted on March 4, 2022 and was active at the time of inspection. There was a release of information form to an emergency contact; however, the dated signature of a witness was not documented.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC clinicians were instructed to sign and date all ROI consent forms. All forms will be signed and dated by the clinicians, reviewed by the clinical director, and until a new EMR is up and running they will be scanned and uploaded to Profiler.
Staff signature and date documenting the new ROI consents has been initiated with current and future clients. Director will review forms before they are scanned ensuring that all of the above was obtained.
Director will audit client charts to monitor the ROI throughout the year. All ROI forms will be reviewed by the Clinical Director after initial intake and scanned and uploaded to Profiler until the new EMR is up and running.
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent to release information form was offered to the client in five of seven client records reviewed.Client #1 was admitted on January 31, 2022 and was active at the time of inspection. Release of information forms to an emergency contact and a primary physician were signed and dated by the client on May 2, 2022. There was no documentation in the record that a copy of both release of information forms were offered to the client.Client #2 was admitted on March 4, 2022 and was active at the time of inspection. A release of information form to a social services center was signed and dated on May 12, 2022. There was no documentation in the record that a copy of the release of information form was offered to the client.Client #3 was admitted on February 28, 2022 and was active at the time of inspection. Release of information forms to an emergency contact and an attorney were signed and dated by the client on August 5, 2021. There was no documentation in the record that a copy of both release of information forms were offered to the client.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021. A release of information form to a public defender was signed and dated by the client on February 22, 2021. There was no documentation in the record that a copy of the release of information form was offered to the client.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022. A release of information form to an emergency contact was signed and dated by the client on November 12, 2021. There was no documentation in the record that a copy of the release of information form was offered to the client.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC clinicians were instructed to state the purpose of the ROI form and offer the client the right to accept or refuse a copy of the form. All forms will be signed by the client's and until a new EMR is up and running they will be scanned and uploaded to Profiler.
Director will audit client charts to monitor the ROI throughout the year. All ROI forms will be reviewed by the Clinical Director after initial intake and scanned and uploaded to Profiler until the new EMR is up and running.
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709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgment by the client that the client had been informed of their right to retain civil rights and liberties except as provided by statute in four of seven client records reviewed.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights, that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, that clients have the right to inspect their own records, that clients have the right to appeal a decision limiting access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, that clients have the right to submit rebuttal data or memoranda to their own records, disclosure to the client of criteria for admission, treatment, completion and discharge, PMHC client policies, PMHC hours of operation, PMHC client fees, and PMHC services provided. Line has been added to the booklet stating "I have been offered a copy of this document. Accepted ( ) Declined ( )" for the client to check-off.
Director has edited the client handbook and client sign-off sheet to address the above issues. All forms now clearly state whether a client has accepted or refused a document.
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709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by the client of their right that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in four of seven client records reviewed.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights, that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, that clients have the right to inspect their own records, that clients have the right to appeal a decision limiting access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, that clients have the right to submit rebuttal data or memoranda to their own records, disclosure to the client of criteria for admission, treatment, completion and discharge, PMHC client policies, PMHC hours of operation, PMHC client fees, and PMHC services provided. Line has been added to the booklet stating "I have been offered a copy of this document. Accepted ( ) Declined ( )" for the client to check-off.
Director has edited the client handbook and client sign-off sheet to address the above issues. All forms now clearly state whether a client has accepted or refused a document.
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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
Based on a review of client records, the facility failed to document the written acknowledgement by the client that the client had been informed of their right to inspect their own records in four of seven client records reviewed. Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights, that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, that clients have the right to inspect their own records, that clients have the right to appeal a decision limiting access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, that clients have the right to submit rebuttal data or memoranda to their own records, disclosure to the client of criteria for admission, treatment, completion and discharge, PMHC client policies, PMHC hours of operation, PMHC client fees, and PMHC services provided. Line has been added to the booklet stating "I have been offered a copy of this document. Accepted ( ) Declined ( )" for the client to check-off.
Director has edited the client handbook and client sign-off sheet to address the above issues. All forms now clearly state whether a client has accepted or refused a document.
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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
Based on a review of client records, the facility failed to document the written acknowledgement by the client that the client had been informed of their right to appeal a decision limiting access to their records to the director in four of seven client records reviewed. Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights, that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, that clients have the right to inspect their own records, that clients have the right to appeal a decision limiting access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, that clients have the right to submit rebuttal data or memoranda to their own records, disclosure to the client of criteria for admission, treatment, completion and discharge, PMHC client policies, PMHC hours of operation, PMHC client fees, and PMHC services provided. Line has been added to the booklet stating "I have been offered a copy of this document. Accepted ( ) Declined ( )" for the client to check-off.
Director has edited the client handbook and client sign-off sheet to address the above issues. All forms now clearly state whether a client has accepted or refused a document.
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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
Based on a review of client records, the facility failed to document the written acknowledgement by the client that the client had been informed of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in four of seven client records reviewed. Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights, that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, that clients have the right to inspect their own records, that clients have the right to appeal a decision limiting access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, that clients have the right to submit rebuttal data or memoranda to their own records, disclosure to the client of criteria for admission, treatment, completion and discharge, PMHC client policies, PMHC hours of operation, PMHC client fees, and PMHC services provided. Line has been added to the booklet stating "I have been offered a copy of this document. Accepted ( ) Declined ( )" for the client to check-off.
Director has edited the client handbook and client sign-off sheet to address the above issues. All forms now clearly state whether a client has accepted or refused a document.
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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
Based on a review of client records, the facility failed to document the written acknowledgement by the client that the client had been informed of their right to submit rebuttal data or memoranda to their own records in four of seven client records reviewed.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights, that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, that clients have the right to inspect their own records, that clients have the right to appeal a decision limiting access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, that clients have the right to submit rebuttal data or memoranda to their own records, disclosure to the client of criteria for admission, treatment, completion and discharge, PMHC client policies, PMHC hours of operation, PMHC client fees, and PMHC services provided. Line has been added to the booklet stating "I have been offered a copy of this document. Accepted ( ) Declined ( )" for the client to check-off.
Director has edited the client handbook and client sign-off sheet to address the above issues. All forms now clearly state whether a client has accepted or refused a document.
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709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of disclosure to the client of criteria for admission, treatment, completion, and discharge four of seven client records reviewed.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights, that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, that clients have the right to inspect their own records, that clients have the right to appeal a decision limiting access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, that clients have the right to submit rebuttal data or memoranda to their own records, disclosure to the client of criteria for admission, treatment, completion and discharge, PMHC client policies, PMHC hours of operation, PMHC client fees, and PMHC services provided. Line has been added to the booklet stating "I have been offered a copy of this document. Accepted ( ) Declined ( )" for the client to check-off.
Director has edited the client handbook and client sign-off sheet to address the above issues. All forms now clearly state whether a client has accepted or refused a document.
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709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project's policies in four of seven client records reviewed.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights, that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, that clients have the right to inspect their own records, that clients have the right to appeal a decision limiting access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, that clients have the right to submit rebuttal data or memoranda to their own records, disclosure to the client of criteria for admission, treatment, completion and discharge, PMHC client policies, PMHC hours of operation, PMHC client fees, and PMHC services provided. Line has been added to the booklet stating "I have been offered a copy of this document. Accepted ( ) Declined ( )" for the client to check-off.
Director has edited the client handbook and client sign-off sheet to address the above issues. All forms now clearly state whether a client has accepted or refused a document.
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709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project's hours of operation in four of seven client records reviewed.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights, that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, that clients have the right to inspect their own records, that clients have the right to appeal a decision limiting access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, that clients have the right to submit rebuttal data or memoranda to their own records, disclosure to the client of criteria for admission, treatment, completion and discharge, PMHC client policies, PMHC hours of operation, PMHC client fees, and PMHC services provided. Line has been added to the booklet stating "I have been offered a copy of this document. Accepted ( ) Declined ( )" for the client to check-off.
Director has edited the client handbook and client sign-off sheet to address the above issues. All forms now clearly state whether a client has accepted or refused a document.
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709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project's fee schedule in four of seven client records reviewed.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights, that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, that clients have the right to inspect their own records, that clients have the right to appeal a decision limiting access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, that clients have the right to submit rebuttal data or memoranda to their own records, disclosure to the client of criteria for admission, treatment, completion and discharge, PMHC client policies, PMHC hours of operation, PMHC client fees, and PMHC services provided. Line has been added to the booklet stating "I have been offered a copy of this document. Accepted ( ) Declined ( )" for the client to check-off.
Director has edited the client handbook and client sign-off sheet to address the above issues. All forms now clearly state whether a client has accepted or refused a document.
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709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to include, during the intake and admission process, documentation of client orientation to the project's provided services in four of seven client records reviewed.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will develop a client handbook that will outline the clients civil rights, that PMHC may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion, that clients have the right to inspect their own records, that clients have the right to appeal a decision limiting access to their records to the director, clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records, that clients have the right to submit rebuttal data or memoranda to their own records, disclosure to the client of criteria for admission, treatment, completion and discharge, PMHC client policies, PMHC hours of operation, PMHC client fees, and PMHC services provided. Line has been added to the booklet stating "I have been offered a copy of this document. Accepted ( ) Declined ( )" for the client to check-off.
Director has edited the client handbook and client sign-off sheet to address the above issues. All forms now clearly state whether a client has accepted or refused a document.
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of the type of services the client is to receive on the client's individual treatment plan in three of six applicable client records reviewed. Client #1 was admitted on January 31, 2022 and was active at the time of inspection. The comprehensive treatment plan was dated February 14, 2022.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021. The comprehensive treatment plan was dated October 11, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022. The comprehensive treatment plan was dated December 1, 2021.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
PMHC will have the clinician state the frequency needed with respect to treatment, individuals, and group therapy discussed in treatment plan. The client will know exactly how many times a week they must attend treatment in their specific program GOP/IOP.
Director instructed clinician's and will review all client treatment plans to include frequency of services and modality. Further they will spell out for the client the weekly attendance needed for treatment in their specific program GOP/IOP.
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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
Based on a review of client records, the facility failed to ensure that all treatment plans were reviewed and updated at least every 60 days in two of four applicable client records reviewed.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021. The comprehensive treatment plan was completed on October 11, 2021 and the first update was due no later than December 11, 2021. However, the update was not completed prior to the client's discharge.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022. The comprehensive treatment plan was completed on December 1, 2021 and the first update was due no later than February 1, 2022. However, the update was not completed prior to the client's discharge.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC will have clinicians update all treatment plans every 60 days. Clinicians will maintain a spreadsheet addressing treatment plans, case consults, ROI's, and authorization of insurance.
Director instructed clinician's and will review, during supervision, all client treatment plans to assure 60 day window is adhered to and clinicians have developed a spreadsheet to maintain due dates treatment plans, case consults, ROI's, and authorization of insurance .
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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.
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Observations
Based on a review of client records, the facility failed to maintain a complete client record on an individual, which is to include follow-up information, in four of four applicable client records reviewed.Client #4 was admitted on September 29, 2021 and was discharged on October 15, 2021.Client #5 was admitted on October 11, 2021 and was discharged on December 16, 2021.Client #6 was admitted on December 1, 2021 and was discharged on February 8, 2022.Client #7 was admitted on January 31, 2022 and was discharged on April 18, 2022.This is a repeat citation from the July 28, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PMHC staff will complete spreadsheet documenting client follow-up upon discharge that will be maintained and reviewed on a monthly basis.
Director will review all discharges, during supervision, and the log document that client follow-up was completed on a monthly basis.
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709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display a telephone number to the general public for emergency purposes. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
PHMC will replace the paper sign on the front door with metal signage by 7/1/2022.
Director has ordered a metal sign to be hung on front door for hours of operation and phone number for the facility by 7/1/2022.
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