INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5-7, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Montgomery County MH/MR Emergency Service, Inc., 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 April 3, 2008.
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Plan of Correction
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709.122(b)(5) LICENSURE Follow-up
709.122. Detoxification.
(b) Client records. 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:
(5) Follow-up information.
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Observations
Based upon a review of client records on March 7, 2008, the facility failed to conduct a follow-up for two of three records reviewed in accordance with facility policy, #2 & 3.
Client record #2 lacked documentation that a follow-up was conducted within 7 days of the clients scheduled appointment for outpatient treatment..
Client record #3 had a follow-up dated 3/4/08 when the client had been discharged from Montgomery County MH/MR Emergency Service on 9/4/07. This exceeded the facility's 7 day policy.
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Plan of Correction
Due to staff turnover in the Social Service Department, follow-up calls were inadvertently missed. Social Service staff were reeducated at their staff meeting (3/20/08) by the Director of Medical Records as to the need and importance of follow-up calls. Caseworkers were given a checklist of items that need to be done specifically for D&A clients (since our volume is minimal). Documentation of the follow-up calls will be done by the caseworker. Monitoring will be done by the Medical Records Department and Director of Social Service. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based upon a review of the facility's Annual Report on March 5, 2008, the facility failed to include a statement of income and expenses.
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Plan of Correction
When the next Annual Report is completed for fiscal year 2007/2008 (in June 2008), the Chief Financial Officer will ensure that a statement of income and expenses is included. The CFO will ensure that this information is included in all future Annual Reports as required by D&A. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based upon a review of the facility's policies and procedures manual on March 5, 2007, the facility failed to ensure the confidentiality of clients in Drug and Alcohol treatment in accordance with 4 Pa Code 255.5; 71 PS and 42 CFR Part 2, Subpart B, Subsection 2.14(b).
The findings were:
1. Montgomery County Emergency Service (MCES) failed to clearly identify in their policy and procedures manual the scenarios when the facility may release client identifying information without the client's consent.
Item 3 on Page 16 Section M of MONTGOMERY COUNTY EMERGENCY SERVICE CONFIDENTIALITY POLICY states: Law or statutory regulation requires the hospital to report certain conditions, including child or patient abuse.
2. The facility's policy and procedure manual included policies and procedures that failed to recognize the consent of a minor as valid and binding as if the minor had achieved his majority in accordance with 71 P.S. and 42 CFR Part 2, Subpart B, subsection 2.14(b).
Montgomery County Emergency Service, Inc. Informed Consent Policy Section II fails to adhere to the above mentioned regulations based upon the following statements contained within the policy.
Section II, Item #5 Competent minors, 14 years and older, states that when confidential services are requested, MCES encourages these minors to involve their parents, unless this involvement is judged to be detrimental and clinically contraindicated. If a minor, 14 years and older, objects to parental involvement, his/her wishes should be respected, except as required by law. In that case, parents will be notified (by telephone when possible and delivery of Form MH-78E). Parents of minors, 14 years and older will be notified of the child's presence at MCES. This notification will include that the minor has been accepted for treatment, an explanation of the proposed treatment, and the right to file an objection (in writing to the CEO/Medical Director or Hospital Administrator.)
Section II, Item #7 Minors, 13 years and younger, states that the clients are legally not able to give informed consent. For these patients, parental involvement is sought and parents give informed consent.
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Plan of Correction
Confidentiality policy (Item 3, Page 16, Section M) to be updated by Medical Records Director to include information that no drug and alcohol information will be released when reporting child or patient abuse. Clients will not be identified as drug and alcohol clients.
Medical Records Director fo further revise the Confidentiality Policy to include other scenarios where patient consent is not needed (as per 255.5 & 42 CFR), i.e. child abuse or suspected child abuse, medical emergency, etc.)
Informed Consent Policy (Section II #5 and #7) to be updated to indicate that these two sections are not applicable to drug and alcohol clients. |
709.93(a) 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:
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Observations
Based upon a review of client records on March 7, 2008, the facility failed to begin and document the discharge procedures in one of two records reviewed, #5.
Client #5 had been admitted for Drug and Alcohol treatment services on 5/29/2003, and although the client had been reporting monthly for medication monitoring sessions, the client was last seen for outpatient substance abuse treatment services on 10/9/07. In reviewing the client's treatment plans and progress notes, as far back as 2004, the client has successfully completed the requirements for the D&A aspect of treatment and treatment plans beyond 2004 were more suited for MH/MR issues.
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Plan of Correction
Discharge summary has been dicated by the psychiatrist discharging the client from the Outpatient Drug and Alcohol Program. However, this client will continue receiving treatment in the Mental Health Outpatient Program.
Outpatient Secretary to monitor D&A outpatient charts and review with the therapist when D&A issues appear to be resolved. Discharge summaries will then be dictated by the therapist within 7 days of discharge. |
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.
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Observations
Based upon a review of client records on March 7, 2008, the facility failed to conduct a case consultation within 90 days, as per facility policy, in one of two records reviewed, #5.
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Plan of Correction
Therapist has been reeducated on the need to have case consultations done annually for the sole D&A client remaining in the program. Notes will be dictated as "case consultations." Monitoring for compliance will be done by the Outpatient Secretary. |
709.93(a)(10) 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:
(10) Discharge summary.
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Observations
Based upon a review of client records on March 7, 2008, the facility failed to ensure that the discharge summary in one of one records reviewed, #4, had been completed within seven days of the client's discharge. The form lacked a dated signature to verify when the summary had been completed.
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Plan of Correction
Discharge summaries will be completed by therapists within 7 days of discharge from the Drug and Alcohol Outpatient Program. Discharge summaries will be signed and dated within 7 days of discharge. Monitoring for compliance will be done by the Outpatient Secretary. |