INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 21 - 22, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mon Yough Community Services 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.
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Plan of Correction
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709.26(e)(2) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(2) The employe's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
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Observations
Based on a review of the policy and procedure manual, employee handbook and personnel records, the facility failed to document written policies on employee rights and demonstrate the project's efforts toward informing staff of the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records in one of one personnel records.
The findings include:
The policy and procedure manual and employee handbook were reviewed on September 21, 2011. The facility failed to document a written policy on the employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records, as required by regulation. Five personnel records were reviewed on September 21, 2011. One personnel record pertained to a new employee and required documentation that the employee was informed of the right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information form the records. The facility failed to inform employee # 3 of the right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
Employee # 3 was hired by the facility on January 18, 2011. Employee # 3 was provided an employee handbook and the personnel policies and procedures on December 13, 2010. The employee handbook and the personnel policies and procedures did not include the right of the employee to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
The facility director was interviewed throughout the licensing process and confirmed this employee right was not included in the personnel policies or employee handbook. Human Resources staff were interviewed on September 21, 2011 at approximately 3:00 PM and confirmed the findings.
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Plan of Correction
709.26(e)(2) LICENSURE
Personnel Management:
709.26. Personnel management. (e) The project director shall develop written policies on employee rights and demonstrate the project's efforts toward informing staff of the following: (2) The employee's right to request the correction or removal of inaccurate, irrelevant, outdated or incomplete information from the records.
Plan of Correction
MYCS will include the below information in the Employee handbook section "Personnel Records" by December 1, 2011. The employee's have a right to request the correction or removal of inaccurate, irrelevant outdated or incomplete information from the records. The employee's have the right to submit rebuttal data or memoranda to his own record.
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709.26(e)(3) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
(3) The employe's right to submit rebuttal data or memoranda to his own records.
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Observations
Based on a review of the policy and procedure manual, employee handbook and personnel records, the facility failed to document written policies on employee rights and demonstrate the project's efforts toward informing staff of the employee's right to submit rebuttal data or memoranda to his own records in one of one personnel records.
The findings include:
The policy and procedure manual and employee handbook were reviewed on September 21, 2011. The facility failed to document a written policy on the employee's right to submit rebuttal data or memoranda to his own records, as required by regulation. Five personnel records were reviewed on September 21, 2011. One personnel record pertained to a new employee and required documentation that the employee was informed of the right to submit rebuttal data or memoranda to his own records. . The facility failed to inform employee # 3 of the right to submit rebuttal data or memoranda to his own records.
Employee # 3 was hired by the facility on January 18, 2011. Employee # 3 was provided an employee handbook and the personnel policies and procedures on December 13, 2010. The employee handbook and the personnel policies and procedures did not include the right of the employee to submit rebuttal data or memoranda to his own records.
The facility director was interviewed throughout the licensing process and confirmed this employee right was not included in the personnel policies or employee handbook. Human Resources staff were interviewed on September 21, 2011 at approximately 3:00 PM and confirmed the findings.
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Plan of Correction
709.26(e)(3) LICENSURE
Personnel Management:
709.26. Personnel management. (e) The project director shall develop written policies on employee rights and demonstrate the project's efforts toward informing staff of the following: (3) The employee's right to submit rebuttal data or memoranda to his own records.
Plan of Correction
MYCS will include the below information in the Employee handbook section "Personnel Records" by December 1, 2011. The employee's have a right to request the correction or removal of inaccurate, irrelevant outdated or incomplete information from the records. The employee's have the right to submit rebuttal data or memoranda to his own record.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
Based on a review of client records, the facility failed to document a physician signature on treatment plans and treatment plan updates, as required by 55 Pa. Code Part III, Chapter 1223 of the Medical Assistance regulations, in three of four client records.
The findings include:
Twelve client records were reviewed on September 22, 2011. Four clients were receiving Medical Assistance funding. These four client records were reviewed for compliance with the Medical Assistance regulations. Per 55 Pa. Code Part III, 1223.52 (6)(i)(ii) of the Medical Assistance regulations, the clinic's supervisory physician shall sign and date the treatment plan and shall review and update each patient's treatment plan. Each review and update shall be dated, documented and signed in the patient's record by the clinic's supervisory physician. The facility failed to document a physician signature on treatment plans and treatment plan updates in client records # 2, 4 and 5.
Client # 2 was admitted into treatment on February 28, 2011. The treatment plan for client # 2 was completed on February 28, 2011. Treatment plan updates were completed on April 28 and June 28, 2011. The treatment plan and updates were signed by a C.R.N.P. (certified registered nurse practitioner). The treatment plan and updates were not signed by a physician, as required by the Medical Assistance regulations.
Client # 4 was admitted into treatment on June 22, 2011. The treatment plan for client # 4 was completed on June 22, 2011. The treatment plan was not signed by a physician, as required by the Medical Assistance regulations. The physician signature line on the treatment plan was blank.
Client # 5 was admitted into treatment on March 15, 2011. The treatment plan for client # 5 was completed on March 15, 2011. Treatment plan updates were completed on May 18 and July 15, 2011. The treatment plan and updates were signed by a C.R.N.P. (certified registered nurse practitioner). The treatment plan and updates were not signed by a physician, as required by the Medical Assistance regulations.
The facility director was interviewed throughout the licensing process and confirmed these clients were receiving Medical Assistance funding. The facility director also confirmed the physician did not sign off on the treatment plans and updates in client records # 2, 4 and 5.
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Plan of Correction
709.94(g) LICENSURE
Project management services:
709.94. Project management services. (g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
Plan of Correction
The clinic's supervisory physician shall sign and date the treatment plan and shall review and update each patient's treatment plan. Each review and update shall be dated, documented and signed in the patient's record by the clinic's supervisory physician. MYCS will explore a waiver from Medical Assistance to allow the CRNP (certified registered nurse practitioner), who has a collaborative agreement with the clinics supervisory physician, to sign and date the treatment plan and review and update each patient's treatment plan. This will occur by November 1, 2011.
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