INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 25 - 26, 2010 by staff from the Division of Drug and Alcohol 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 and a plan of correction is due on November 26, 2010.
|
Plan of Correction
|
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a consent to treatment in nine of sixteen outpatient client records, as required.
The findings include:
Sixteen client records were reviewed on October 25 - 26, 2010. Sixteen client records were required to contain a consent to treatment form. Per regulation, intake procedures shall include documentation of a consent to treatment. The facility utilizes an initial registration form as part of the intake process. Prior to February of 2010, the initial registration form had also contained the client's consent to treatment. In February of 2010, the initial registration form was revised and the following statement was excluded from the form: "I hereby consent to treatment at Mercy Behavioral Health". The facility failed to document a consent to treatment in client records # 1, 2, 3, 4, 5, 8, 13, 15 and 16.
Client # 1 was admitted to the program on April 23, 2010. Client record # 1 did not include a consent to treatment.
Client # 2 was admitted to the program on July 12, 2010. Client record # 2 did not include a consent to treatment.
Client # 3 was admitted to the program on February 19, 2010. Client record # 3 did not include a consent to treatment.
Client # 4 was admitted to the program on April 23, 2010. Client record # 4 did not include a consent to treatment.
Client # 5 was admitted to the program on April 6, 2010. Client record # 5 did not include a consent to treatment.
Client # 8 was admitted to the program on April 9, 2010. Client record # 8 did not include a consent to treatment.
Client # 13 was admitted to the program on May 28, 2010. Client record # 13 did not include a consent to treatment.
Client # 15 was admitted to the program on February 25, 2010. Client record # 15 did not include a consent to treatment.
Client # 16 was admitted to the program on April 21, 2010. Client record # 16 did not include a consent to treatment.
On October 26, 2010, the facility director confirmed that the initial registration form was revised in February of 2010 and the consent to treatment statement was accidentally excluded.
|
Plan of Correction
The statment that was removed in
the February 2010 revision has been
returned to the form. "I hereby
consent to participate in treatment
at Mercy Behavioral Health" was
added on October 14, 2010. All
project staff have been notified of
the previous error in removing the
statement and the subsequent fix.
Facility Director facilitiated the
correct and communicated the
correction to all project staff on
November 8, 2010.
|
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 the review of client records and an interview with the facility director, the facility failed to document follow up in four of four client records, as required.
The findings include:
Sixteen client records were reviewed on October 25 - 26, 2010. Eight client records were closed and four client records required the completion of a follow up. Per regulation, there shall be a complete client record on an individual which includes information relative to the client's involvement with the project and shall include follow-up information. Per agency policy, follow up is required within six months of the client's discharge from the program. The facility did not document an attempt to follow up on the client in client records # 9, 10, 11 and 12.
Client # 9 was admitted to the program on January 27, 2010 and discharged on March 1, 2010. Follow up was required to be completed no later than September 1, 2010. There was no documentation of a six month follow up attempt in client record # 9.
Client # 10 was admitted to the program on January 20, 2010 and discharged on February 24, 2010. Follow up was required to be completed no later than August 24, 2010. There was no documentation of a six month follow up in client record # 10.
Client # 11 was admitted to the program on November 2, 2009 and discharged on February 17, 2010. Follow up was required to be completed no later than August 17, 2010. There was no documentation of a six month follow up in client record # 11.
Client # 12 was admitted to the program on January 20, 2010 and discharged on March 1, 2010. Follow up was required to be completed no later than September 1, 2010. There was no documentation of a six month follow up in client record # 12.
The facility director was interviewed on October 26, 2010. The facility director reported that follow up contact forms are filled out by the counselor upon the client's discharge from the program. The form is then scanned into the computer system and sent to the main office for a follow up letter to be mailed. The facility director confirmed that six month follow up letters had not been mailed to clients # 9, 10, 11 and 12.
|
Plan of Correction
On 11/8/2010, Facility director reviewed with all project staff regulation stating there shall be a complete client record on an individual which includes information relative to the client's involvement with the project and shall include follow-up information, and reviewed that per agency policy, follow up is required within six months of the client's discharge from the program. Standard Operating Proceedure to adhere to this regulation, including correct completion of AOD Follow Up form was reviewed on 11/8/2010 with project staff, and will be monitored with project staff and Health Information Management department for compliance, quarterly. |