INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 14-16, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvnia Associates LLC, dba Mount Pocono Medical 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
The facility failed to prepare alternate exits during its fire drills.
The facilit fire drill records were reviewed as part of the presubmission process, and during the on-site inspection.
The facility records document that the facility used the same two exit routes for every fire drill from February 2018 through October 2018.
These findings were reviewed with the facility staff as part of the inspection process.
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Plan of Correction
The facility failed to prepare alternate exits during its fire drills. The Facility Director & Health & Safety Officer reviewed Fire Safety Regulation with all Mount Pocono Medical Team Member's 11/19/18. A fire drill was conducted on 11/29/18 and one exit was blocked and the alternate exit was used by everyone. Mount Pocono Medical Health & Safety Officer will ensure Fire Drills and Documentation for Fire Drills are in compliance with Fire Safety Regulation. The Facility Director will review all fire drill logs to ensure alternate exits were used and properly documented before approving the drills. |
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 obtain a signed consent to release information form that documented all of the specific information to be disclosed from a client file in one of six patient records reviewed.
The facility documented that it sent a treatment plan and physical exam for Patient #4 to another narcotic treatment facility on April 25, 2018, but the signed consent to release information form dated January 10, 2018, did not list treatment plans or physical exams as information to be disclosed to the facility.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The facility failed to obtain a signed consent to release information form that documented all of the specific information to be disclosed from a client file in one of six patient records reviewed. On December 07th, 2018 the facility director provided an in-house training for Clinical Team in order to review confidentiality and signed consents to release patient information. Training focused on ensuring signed consents to release information list all specific client information being released. It is the responsibility of the Clinical Supervisor and Lead Counselor to ensure that clinical team members are properly trained regarding Confidentiality and that signed consents to release information are completed and documented in accordance with Confidentiality Regulations. Clinical Supervisor and Lead Counselor will ensure signed consents to release information are completed and documented in accordance with Confidentiality Regs., by conducting monthly charts audits. |
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
The facility failed to ensure that all of its clients were informed of their client rights.
A total of seven client records were reviewed during the on-site inspection including one intake, evaluation and referral record. Client #7 was the intake evaluation and referral client. The client's record did not contain written documentation from the client that the client had been notified of the following client 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.
(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.
(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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The facility failed to comply with regulation 709.28 relating to Client Rights. On December 07th, 2018 the facility director provided an in-house training for Mount Pocono Medical's Clinical Team to ensure clients are informed of their client rights upon admission into the program. It is the responsibility of the Clinical Supervisor to ensure that all clients are informed of their rights upon admission and documentation is completed in accordance with Client Rights Regulations. In order to ensure clients are informed of their rights upon admission and documentation is completed in accordance with Client Rights Regulations, clinical supervisor will conduct intake chart audits, along with monthly chart audits to ensure continued compliance. |
715.20(1) LICENSURE Patient transfers
A narcotic treatment program shall develop written transfer policies and procedures which shall require that the narcotic treatment program transfer a patient to another narcotic treatment program for continued maintenance, detoxification or another treatment activity within 7 days of the request of the patient.
(1) The transferring narcotic treatment program shall transfer patient files which include admission date, medical and psychosocial summaries, dosage level, urinalysis reports or summary, exception requests, and current status of the patient, and shall contain the written consent of the patient.
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Observations
The facility failed to ensure that it sent all of the required information to receiving narcotic treatment programs for patients that transferred to the other narcotic treatment programs.
There were six narcotic treatment program patient records reviewed during the on-site inspection. Three of the six narcotic treatment program patient records reviewed were for patients who transferred out of the facility into other narcotic treatment programs.
Patient #4 was transferred to another narcotic treatment program on August 16, 2018, but the facility did not document that it sent the patient's psychosocial summary to the receiving narcotic treatment program.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The facility failed to ensure that it sent all of the required information to receiving narcotic treatment programs for patient that transferred to the other narcotic treatment programs. On December 07th, 2018 the facility director provided an in-house training for Clinical Team in order to review Patient Transfer Regulation and Facility Procedures Relating to Patient Transfer's. Training focused on ensuring Clinical Team Members submit all required information to receiving narcotic treatment program for patient as per Patient Transfers Regulation. It is the responsibility of the Clinical Supervisor to ensure that clinical team members are properly trained regarding Patient Transfers and that all Required Information is submitted to receiving narcotic treatment program and documented in accordance with Patient Transfer Regulation. Clinical supervisor will ensure all required information is submitted to receiving narcotic treatment program and documented in accordance with Patient Transfer Regulation, by reviewing potential/pending transfer client charts prior to transfer and completing monthly discharged chart audits. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
The facility failed to document a signed consent to treatment form in 1 of 1 intake, evaluation and referral client records.
Client #7 was admitted for intake, evaluation and referral on August 15, 2018.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The facility failed to document a signed consent to treatment form in 1 of 1 intake, evaluation and referral client records. On December 07th, 2018 the facility director provided an in-house training for Mount Pocono Medical Team to ensure all intake staff have clients review & sign a consent to treatment form during intake. It is the responsibility of the Clinical Supervisor to review all intake charts and ensure consent to treatment forms are signed by all intake clients and documented in accordance with Consent to TX Regulation. |