INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD Lower Merion Counseling Services 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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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of training during the facility's January 1, 2020 through December 31, 2020 training year.
Employee #1 was hired as the Project Director on February 28, 2018. The personnel record documented 2 hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
D&A Supervisor will assure that Employee #1 completes 12 annual training hours each calendar year.
D&A Supervisor or designee will obtain quarterly updates from the Division Coordinator on total training hours for Employee #1 throughout the calendar year. D&A Supervisor will alert the Unit and Regional Directors if progress of training hours may not be sufficient to meet 12 hr requirement by end of calendar year.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's July 2020 through February 2021 fire drill log, the facility failed to ensure that unannounced fire drills were conducted at least once a month. There was no documentation that a fire drill was conducted for the months of July 2020 through January 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LMCMS will maintain the annual fire drill schedule and the director will sign off monthly that fire drills have occurred. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in five of five applicable client records reviewed.
Client # 1 was admitted on June 21, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 3 was admitted on September 25, 2019 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 4 was admitted on January 10, 2020 and was discharged on June 25, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 5 was admitted on April 15, 2020 and was discharged on August 27, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 7 was admitted on February 12, 2020 and was discharged on June 25, 2020. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on releases of information. Verbal consent to release this information was provided by clients.
A list of clients seen for D&A services from 03/02/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Clinical Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, releases of information will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made by 5/31/2021.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures.
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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
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two of six applicable client records reviewed.
Client # 3 was admitted on September 25, 2019 and was still active at the time of the inspection. The record contained a consent to release information form to the parole officer, signed and dated by the client on September 25, 2019, that allowed for the release of "Drug and Alcohol Records", which exceeds the limits established by 4 Pa. Code 255.5.
Client # 4 was admitted on January 10, 2020 and was discharged on June 25, 2020. The record contained a consent to release information form to the parole officer, signed and dated by the client on January 10, 2020, that allowed for the release of "Drug and Alcohol Records", which exceeds the limits established by 4 Pa. Code 255.5.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on releases of information. Verbal consent to release this information was provided by clients.
A list of clients seen for D&A services from 03/02/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Clinical Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, releases of information will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made by 5/31/2021.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures.
To address ongoing needs regarding the collection of ROIs, LMCMS will conduct a ROI training for all DDAP staff to review how to properly complete a ROI. Clinical Director will ensure that D&A consents are limited to the 5 points of Confidentiality under 255.5. Clinical Director will be holding a training for D&A staff on the appropriate ways to fill out and complete consents and ensuring they are uploaded. Clinical Director with the aid of D&A supervisor will host a training by 5/31/2021 to review the consent process, requirements, regulations, and timelines. Clinical director and Clinical Supervisor will ensure sign off on the training is provided and placed into the HR files of staff as proof of completion.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in two of seven client records reviewed.
Client # 2 was admitted on March 6, 2020 and was still active at the time of the inspection. The release of information forms to the emergency contact, the primary care physician and the pharmacy were signed and dated by the client on March 11, 2020, but all the release of information forms did not document the purposes of the disclosures.
Client # 7 was admitted on February 12, 2020 and was discharged on June 25, 2020. The release of information form to the emergency contact was signed and dated by the client on February 12, 2020, but the release of information form did not document the purpose of the disclosure.
This findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on releases of information. Verbal consent to release this information was provided by clients.
A list of clients seen for D&A services from 03/02/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Clinical Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, releases of information will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made by 5/31/2021.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures.
To address ongoing needs regarding the collection of ROIs, LMCMS will conduct a ROI training for all DDAP staff to review how to properly complete a ROI. Clinical Director will ensure that D&A consents are limited to the 5 points of Confidentiality under 255.5. Clinical Director will be holding a training for D&A staff on the appropriate ways to fill out and complete consents and ensuring they are uploaded. Clinical Director with the aid of D&A supervisor will host a training by 5/31/2021 to review the consent process, requirements, regulations, and timelines. Clinical director and Clinical Supervisor will ensure sign off on the training is provided and placed into the HR files of staff as proof of completion.
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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
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that 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 and that no client may be deprived of a civil right solely by reason of treatment in seven of seven client records reviewed.
Client #1 was admitted on June 1, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #2 was admitted on March 6, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on September 25, 2019 and was discharged on December 18, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that 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 and that no client may be deprived of a civil right solely by reason of treatment.
Client #4 was admitted on January 10, 2020 and was discharged on June 25, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that 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 and that no client may be deprived of a civil right solely by reason of treatment.
Client #5 was admitted on April 15, 2020 and was discharged on August 27, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #6 was admitted on December 17, 2019 and was discharged on May 4, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that 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 and that no client may be deprived of a civil right solely by reason of treatment.
Client #7 was admitted on February 12, 2020 and was discharged on June 25, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection. The client rights acknowledgement documented in the record at the time of the inspection did not include that 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 and that no client may be deprived of a civil right solely by reason of treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on Client Rights. Verbal consent to Client Rights information was provided by clients.
A list of clients seen for D&A services from 03/02/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Clinical Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, Client Rights will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made by 5/31/2021.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures.
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709.30 (2) 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.
(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.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right that 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 in three of seven client records reviewed.
Client #1 was admitted on June 1, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #2 was admitted on March 6, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #5 was admitted on April 15, 2020 and was discharged on August 27, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on Client Rights. Verbal consent to Client Rights information was provided by clients.
A list of clients seen for D&A services from 03/02/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Clinical Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, Client Rights will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made by 5/31/2021.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures.
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709.30 (3) 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.
(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.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to inspect their own records, that 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 and that reasons for removing sections shall be documented in the record in seven of seven client records reviewed.
Client #1 was admitted on June 1, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #2 was admitted on March 6, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on September 25, 2019 and was discharged on December 18, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to inspect their own records, that 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 and that reasons for removing sections shall be documented in the record.
Client #4 was admitted on January 10, 2020 and was discharged on June 25, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to inspect their own records, that 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 and that reasons for removing sections shall be documented in the record.
Client #5 was admitted on April 15, 2020 and was discharged on August 27, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #6 was admitted on December 17, 2019 and was discharged on May 4, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to inspect their own records, that 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 and that reasons for removing sections shall be documented in the record.
Client #7 was admitted on February 12, 2020 and was discharged on June 25, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to inspect their own records, that 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 and that reasons for removing sections shall be documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on Client Rights. Verbal consent to Client Rights information was provided by clients.
The QA Manager updated the LMCMS Clients Rights and Responsibilities on 4/7/2021 to include clients' right to inspect their own records, that facility staff or clinical director may temporarily remove portions determined to be detrimental, and the reasons for removal will be documented in the record.
A list of clients seen for D&A services from 03/02/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Clinical Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, Client Rights will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made by 5/31/2021.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures.
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709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to appeal a decision limiting access to their records to the director in seven of seven client records reviewed.
Client #1 was admitted on June 1, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #2 was admitted on March 6, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on September 25, 2019 and was discharged on December 18, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to appeal a decision limiting access to their records to the director in the record.
Client #4 was admitted on January 10, 2020 and was discharged on June 25, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to appeal a decision limiting access to their records to the director in the record.
Client #5 was admitted on April 15, 2020 and was discharged on August 27, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #6 was admitted on December 17, 2019 and was discharged on May 4, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to appeal a decision limiting access to their records to the director in the record.
Client #7 was admitted on February 12, 2020 and was discharged on June 25, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to appeal a decision limiting access to their records to the director in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on Client Rights. Verbal consent to Client Rights information was provided by clients.
The QA Manager updated the LMCMS Clients Rights and Responsibilities on 4/7 to include clients' right to appeal a decision limiting access to their records to the director.
A list of clients seen for D&A services from 03/02/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Clinical Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, Client Rights will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made by 5/31/2021.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures.
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709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in seven of seven client records reviewed.
Client #1 was admitted on June 1, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #2 was admitted on March 6, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on September 25, 2019 and was discharged on December 18, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client #4 was admitted on January 10, 2020 and was discharged on June 25, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client #5 was admitted on April 15, 2020 and was discharged on August 27, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #6 was admitted on December 17, 2019 and was discharged on May 4, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Client #7 was admitted on February 12, 2020 and was discharged on June 25, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on Client Rights. Verbal consent to Client Rights information was provided by clients.
The QA Manager updated the LMCMS Clients Rights and Responsibilities on 4/7/2021 to include clients' right to appeal a decision limiting access to their records to the director.
A list of clients seen for D&A services from 03/02/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Clinical Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, Client Rights will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made by 5/31/2021.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in seven of seven client records reviewed.
Client #1 was admitted on June 1, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #2 was admitted on March 6, 2020 and was still active at the time of the inspection. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #3 was admitted on September 25, 2019 and was discharged on December 18, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to submit rebuttal data or memoranda to their own records.
Client #4 was admitted on January 10, 2020 and was discharged on June 25, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to submit rebuttal data or memoranda to their own records.
Client #5 was admitted on April 15, 2020 and was discharged on August 27, 2020. There was no client rights acknowledgement documented in the record at the time of the inspection.
Client #6 was admitted on December 17, 2019 and was discharged on May 4, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to submit rebuttal data or memoranda to their own records.
Client #7 was admitted on February 12, 2020 and was discharged on June 25, 2020. The client rights acknowledgement documented in the record at the time of the inspection did not include that a client has the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to provision of telehealth services, this provider did not obtain physical signatures on Client Rights. Verbal consent to Client Rights information was provided by clients.
The QA Manager updated the LMCMS Clients Rights and Responsibilities on 4/7/2021 to include clients' right to appeal a decision limiting access to their records to the director.
A list of clients seen for D&A services from 03/02/2020 (when verbal consent process began) until present will be pulled from databases to identify clients affected by verbal release provision.
All clients will be contacted to be given the option to: come in person to sign necessary forms, have forms mailed to them (if choosing this option, clients will have to mail forms back via SASE), have forms emailed to them via encrypted message (if choosing this option, clients will need access to print/scan signature items back to staff).
Clinical Staff will meet in person with clients who choose this option to review paperwork. Charts will be earmarked prior to visit to identify physical signatures needed.
If clients choose mail/email option, Client Rights will be mailed/emailed to client for signature. Staff will review the content of this information again to ensure the client understands the information contained therein.
Documentation will be included in all charts to indicate when client was contacted, which method of delivery they opted for, when the appointment and/or documents were sent to them, and any necessary follow up attempts made by 5/31/2021.
Moving forward, while still providing telehealth services, therapists will notify clients of any upcoming documentation that is in need of a physical signature and make arrangements based on client preference to obtain signatures. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
Based on a review of the facility's policy and procedure manual and client records, the facility failed to develop and implement a written policy and procedure regarding all medications used by clients. During the physical plant inspection, it was found that the medication,Vivitrol, was being stored onsite. Additionally, during the review of client records, there was documentation that Vivitrol was being administered at the facility; however, during a review of the policy and procedure manual, there was no documented policy and procedure regarding Vivitrol in place.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The QA Manager will revise and expand the LMCMS medication control policy to include Vivitrol storage and administration by 3/26/2021. The policy revisions will be reviewed and approved by the Unit and Clinical Directors. The new policy will go into effect immediately upon approval of the Unit and Clinical Directors. |
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.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in five of seven client records reviewed.
Client #1 was admitted on June 1, 2020 and was still active at the time of the inspection. The individual treatment plan was completed on June 5, 2020 but it did not document the type and frequency of treatment and rehabilitation services.
Client #2 was admitted on March 6, 2020 and was still active at the time of the inspection. The individual treatment plan was completed on March 11, 2020 but it did not document the type of treatment and rehabilitation services.
Client #3 was admitted on September 25, 2019 and was discharged on December 18, 2020. The individual treatment plan was completed on September 25, 2019 but it did not document the type of treatment and rehabilitation services.
Client #5 was admitted on April 15, 2020 and was discharged on August 27, 2020. The individual treatment plan was completed on April 22, 2020 but it did not document the type and frequency of treatment and rehabilitation services.
Client #7 was admitted on February 12, 2020 and was discharged on June 25, 2020. The individual treatment plan was completed on February 12, 2020 but it did not document the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure that individual treatment plans are in compliance, the Clinical Director and D&A Supervisor will conduct a training for all D&A staff on how to document the type and frequency of treatment and rehabilitation services on the treatment plan. The training will be completed by all D&A staff by 5/20/2021 and will include the type and frequency of treatment and rehabilitation services. The training will be designed and conducted by the D&A Supervisor and Clinical Director. The training will review the requirements around Goals/ Objectives and Interventions. The training will review with the timeline regarding regulations and expected due dates of treatment plans as well as how to document treatment plans in the absence of the client when necessary in order to remain in compliance.
Effective immediately and moving forward, if the treatment plan cannot be completed in coordination with the client the D&A therapist will still complete the treatment plan. In these situations, the therapist will notate that the signature was not obtained due to lack of collaboration with the client and the therapist will offer details surrounding the client's treatment and reasons behind the limited attendance.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update each client's treatment plan at least every 60 days in seven of seven client records reviewed.
Client # 1 was admitted on June 1, 2020 and was still active at the time of the inspection. The comprehensive treatment plan was completed on June 5, 2020 and the next update was due no later than August 5, 2020; however, the update was not completed until June 26, 2020. Additionally, a treatment plan update was completed on October 7, 2020 and the next update was due no later than December 7, 2020; however, the update was not completed until December 27, 2020.
Client # 2 was admitted on March 6, 2020 and was still active at the time of the inspection. A treatment plan update was completed on October 2, 2020, and the next update was due no later than December 2, 2020; however, the update was not completed until February 3, 2021.
Client # 3 was admitted on September 25, 2019 and was still active at the time of the inspection. The comprehensive treatment plan was completed on September 25, 2019 and the next update was due no later than November 25, 2019; however, the update was not completed until January 17, 2020. Additionally, a treatment plan update was completed on March 31, 2020 and the next update was due no later than May 31, 2020; however, the update was not completed until June 22, 2020.
Client # 4 was admitted on January 10, 2020 and was discharged on June 25, 2020. The comprehensive treatment plan was completed on January 10, 2020 and the next update was due no later than March 10, 2020; however, the update was not completed until April 1, 2020.
Client # 5 was admitted on April 15, 2020 and was discharged on August 27, 2020. The comprehensive treatment plan was completed on April 22, 2020, and the next update was due no later than June 22, 2020; however, the update was not completed prior to discharge.
Client # 6 was admitted on December 17, 2019 and was discharged on May 5, 2020. The comprehensive treatment plan was completed on January 10, 2020, and the next update was due no later than March 10, 2020; however, the update was not completed prior to discharge.
Client # 7 was admitted on February 12, 2020 and was discharged on June 25, 2021. The comprehensive treatment plan was completed on February 12, 2020, and the next update was due no later than April 12, 2020; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure that individual treatment plans are in compliance, the Clinical Director and D&A Supervisor will conduct a training for all D&A staff on how to document the type and frequency of treatment and rehabilitation services on the treatment plan. The training will be completed by all D&A staff by 5/20/2021 and will include the type and frequency of treatment and rehabilitation services. The training will be designed and conducted by the D&A Supervisor and Clinical Director. The training will review the requirements around Goals/ Objectives and Interventions. The training will review with the timeline regarding regulations and expected due dates of treatment plans as well as how to document treatment plans in the absence of the client when necessary in order to remain in compliance.
Effective immediately and moving forward, if the treatment plan cannot be completed in coordination with the client the D&A therapist will still complete the treatment plan. In these situations, the therapist will notate that the signature was not obtained due to lack of collaboration with the client and the therapist will offer details surrounding the client's treatment and reasons behind the limited attendance.
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