INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 6, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mercy House Of Meadville, 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 May 4, 2010.
|
Plan of Correction
|
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
Based on the review of the policy and procedure manual, the facility failed to develop a written procedure that complied with 4 Pa Code 255.5 with regards to the confidentiality of client identity and recordsThe findings include:The policy and procedures manual was reviewed on April 6, 2010. The policy regarding the confidentiality of the client identity and records states " in the event that an insurance company, health or hospital plan remains dissatisfied with the content of the information released with regards to the client in accordance with this paragraph, such insurance company, health or hospital plan may apply to the executive director for additional information with the written consent of the client and, upon approval by the executive director, said information may be released. This exceeds that which is permitted under 4 Pa. Code Subsection 255.5(a)(7)(b). The term "Executive Director" as used in this regulation refers to the Executive Director of the Governor's Council on Drug and Alcohol Abuse. The authority identified at 4 Pa. Code subsection 255.5(a)(7)(b) now rests with the Secretary of Health.
|
Plan of Correction
Because the statement, {" in the event that an insurance company, health or hospital plan remains dissatisfied with the content of the information released with regards to the client in accordance with this paragraph, such insurance company, health or hospital plan may apply to the executive director for additional information with the written consent of the client and, upon approval by the executive director, said information may be released,"} exceeds that which is permitted under 4 Pa. Code Subsection 255.5(a)(7)(b). The term "Executive Director" as used in this regulation refers to the Executive Director of the Governor's Council on Drug and Alcohol Abuse. The authority identified at 4 Pa. Code subsection 255.5(a)(7)(b) now rests with the Secretary of Health), the phrase in the ellipses was deleted by facility director and approved of by the board of incorporators on April 15, 2010.. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client which included the specific information to be disclosed, in one of two client records. The findings include:Five client records were reviewed on April 6, 2010. Two client records were reviewed for compliance with an informed and voluntary consent from the client which included the specific information to be disclosed. The facility did not document an informed and voluntary consent for the specific information to be disclosed in client record # 3. The consent to release information, signed by the client, did not document the specific information to be released. This section of the release was not completed.
|
Plan of Correction
The Clinical supervisor held a staff meeting on Thursday April 15, 2010 to review how to correctly fill out an authorization for release of information. Staff members were advised that information to be released needed to state specifically what information is to be disclosed. Clinical supervisor and staff will monitor records with regular chart review in order to maintain correct formation of voluntary consent forms. Clinical supervisor will be responsiible for final monitoring of charts. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
|
Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan which included short and long-term goals for treatment in two of two client records. The findings:Five client records were reviewed on April 6, 2010. Two client records were required to have an individual treatment and rehabilitation plan developed which included short and long-term goals for treatment. The facility did not identify whether the stated goals on the client's treatment plan were short or long term goals in client records # 2 and 3.
|
Plan of Correction
To insure compliance that treatment plans inform Clients of goal types, the clinical supervisor trained the staff on the use of a new treatment plan form that will require the use of the words "short term and long term" goals. The meeting occured on April 15, 2010. The clinical supervisor and staff will perform regular chart review to insure that the treatment goals are stated using words "short and long term". |
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.
|
Observations
Based on the review of client records, the facility failed to document individual treatment and rehabilitation plans that included the type and frequency of treatment and rehabilitation services in two of two client records. The findings include: Five client records were reviewed on April 6, 2010. Two client records were reviewed for compliance with the individual treatment and rehabilitation plan which included the type and frequency of treatment and rehabilitation services. The facility did not document the type and frequency of treatment and rehabilitation services in client records # 2 and 3. In client record # 2, the type and frequency were listed as Track 6. It did not specify what type of counseling or the frequency of counseling the client was to be receiving. Individual counseling was listed as PRN.In client record # 3, the type and frequency were listed as Track 3. It did not specify what type of counseling or the frequency of counseling the client was to be receiving. Individual counseling was listed as every other week or as the client's schedule permits.
|
Plan of Correction
To comply with the treatment and rehabilitation services codes that inform the client in writing as to the type and frequency of treatment and rehabilitation services, a new treatment plan form was instituted that removed the track # of service and provided lines to specifically describe the types and frequency of services. The clinical supervisor held a meeting with the staff on April 15, 2010 to train staff on implementation of the new form. Clinical supervisor and staff will perform regular chart review to insure proper documentation of treatment plan type and frequency. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to document goals with timeframes in the aftercare plan in one of one client record. The findings include:Five client records were reviewed on April 6, 2010. An aftercare plan was required in one client record. The facility did not document the timeframes for the completion of goals documented in the client's aftercare plan in client record # 4.
|
Plan of Correction
The clinical supervisor had a staff meeting on April 15, 2010 to train the staff on the implementation of a new aftercare plan form that has lines devoted to timeframes for the completion of the goals documented in the aftercare plan. Compliance will be guaranteed by regular chart review by staff and the clinical supervisor. |
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.
|
Observations
Based on the review of client records, the facility failed to document a discharge summary in one of two client records. The findings include:Five client records were reviewed on April 6, 2010. Two client records were required to have a discharge summary. The facility did not document that a discharge summary was completed for client record # 5.Client # 5 was admitted on December 10, 2009 and discharged on February 4, 2010. There was no discharge summary documented in the client record.The project/facility director confirmed on April 6, 2010 that a discharge summary was not documented in client record # 5.
|
Plan of Correction
In order to have complete client records that summarize a client's treatment experience, the clinical supervisor informed the staff in an April 15, 2010 training that all discharges, including unsuccessful completions required a discharge summary to be performed and noted in a client's file. The clinical supervisor and the staff will conduct regular chart reviews to insure that discharge summaries are completed in all client files. |