INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on December 22, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, MVP Recovery, LLC 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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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
The facility failed to document a dated signature of client or guardian as provided for under 42 CFR2.14(a) and (b) and 2.15 (relating to minor parents; and incompetent and deceased patients) on release of information forms in two of seven client records reviewed.
Client #1 was admitted on July 28, 2020 and active at time of inspection. There were two release of information forms to government agencies that were signed and dated by staff on September 1, 2020; however, the dated signature of the client was not documented.
Client #6 was admitted on September 16, 2020 and discharged on October 29, 2020. A release of information form to a government agency was signed and dated by staff on September 16, 2020; however, the dated signature of the client was not documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will conduct a training session on 1/11/2021 which will be attended by all clinical and administrative staff members during the monthly staff meeting. In this training Executive Director will review the MVP Confidentiality Policy as related to 42 CFR2.14 (a) and (b). Executive Director will also review the proper procedure for capturing electronic signatures on the MVP EMR system. This training conducted by the Executive Director will detail the step by step procedure of capturing all necessary signatures through the MVP EMR system as well as review the MVP Confidentiality Policy. Clinical Staff will be held accountable that all signatures are documented appropriately through continued monthly supervision and plans of correction if necessary. Administrative team will conduct a minimum of monthly audits, and document said audits, to ensure all signatures are documented appropriately. |