INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Merakey Delaware County 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) 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 two of seven client records reviewed.Client # 2 was admitted on January 3, 2022 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on August 19, 2021 and expired on August 19, 2022. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after August 19, 2022. Client # 7 was admitted on July 1, 2022 and was discharged on November 1, 2022. 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 process.
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Plan of Correction
The intake specialist will hand off all completed assessments including all consents and releases to the Intake Director to audit for completion including all signatures and dates before taking the file to medical records. The Medical Records Manager will meet with the Intake Director monthly to report on any missing signatures or information on any consents. The Intake Director will be responsible to ensure that this citation does not re-occur. Both the Clinical Supervisor and Executive Director will provide spot checks to ensure the intake team is obtaining necessary signatures, forms, and following procedure.
Monitoring Checklists will be utilized to ensure completion for all consents and intake packets.
The Medical Records Manager will audit all current active client's charts to ensure the signatures are all completed by March 1, 2023.
All documentation needing corrections will be identified through the audit and will be updated during the next scheduled appointment with the client.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client records reviewed.Client # 6 was admitted on December 20, 2021 and was administratively discharged on July 14, 2022. There was documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project on August 23, 2022; however, the documentation listed the incorrect reason for termination. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All Clients that may be discharged involuntarily will received a verbal warning, followed by a discharge/re-engagement letter indicating the reason for the discharge or attempt to re-engage and describing the appeal process. Any verbal warnings will be documented in the client chart via DAP note or Admin note.
The Clinical Supervisor and the Counselor will discuss the reasons for the discharge and come to an agreement regarding the reason to discharge the client. The conversation between the Clinical Supervisor and the Counselor will be documented in the client's chart.
The client will be given the letter in person or sent to his/her address describing the reasons for the discharge and the appeal process.
The Executive Director will provide spot checks to Clinical Supervisor/Program Director are documenting and performing discharges thoroughly and completely.
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.Client # 6 was admitted on December 20, 2021 and was administratively discharged on July 14, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and the Executive will meet initially to discuss the possible client's involuntarily discharge. Clients that may be discharged involuntarily or administratively will be given a letter explaining the reasons for the potential discharge and explaining the appeal process.
A treatment log will be developed to list all involuntary discharged clients and the outcome of the discharge appeal to ensure this deficiency does not re- occur. The log will be developed by February 15, 2023 and implemented no later than March 1, 2023.
The Clinical Supervisor will maintain this and review the log during regularly scheduled supervision with the Executive Director, to ensure clients who have been involuntarily terminated were sent the letter for discharge and appeal process.
The appeal process which will be documented in the letter to the client is below.
Involuntary Termination Appeal process:
All clients will be notified in writing prior to the start of an involuntary termination and given the opportunity to appeal this clinical decision.
A client has 48 hours to submit in writing, to the Program Director/Clinical Supervisor a Request for Appeal to an involuntary termination.
The Clinical Supervisor will review the appeal with the Program Director and determine a course of action. The decision will be given to the client in writing within 48 hours (or 2 business days) after their request.
If the client disagrees with the decision from the Program Director, they will have 48 hours in which to appeal that decision to the Executive Director of Merakey Delaware County.
The Executive Director will review the appeal and determine a course of action. The decision will be given to the client in writing within 5 working days. If the appeal process is completed, all documentation including the initial discharge letter, the client's letter of appeal and the result of the appeal with be placed in the client's chart.
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