INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 26-27, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Main Line Affiliates dba Mirmont Outpatient 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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711.92(c) LICENSURE Individual TX Plan
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records on October 26-27, 2016, the facility failed to document that the individual treatment and rehabilitation plan was developed with the client in six of fifteen client records.Client #2's individual treatment plan dated 3/14/2016 was not signed by or discussed with the client.Client #3's individual treatment plan dated 4/21/2016 was not signed by or discussed with the client.Client #4's individual treatment plan dated 3/15/2016 was not signed by or discussed with the client.Client #6's individual treatment plan dated 3/24/2016 was not signed by or discussed with the client.Client #8's individual treatment plan dated 1/15/2016 was not signed but stated it was discussed on 1/18/2016 with the client.Client #10's individual treatment plan dated 1/25/2016 was not signed but stated it was discussed on 1/26/2016 with the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The facility will implement new process for treatment plans to be developed with clients and documented date and time of review with client.
2. The Clinical supervisor will complete chart audits monthly evaluating compliance starting 1/2017.
3. The Director of Outpatient Services and Clinical Supervisor are responsible for ensuring corrective action plan implemented.
4. The staff will be trained and educated on process standard of treatment care plans developed with client and reviewed and signed by client on 12/12.
5. The deficiency will be corrected by 1/2017.
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711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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:
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Observations
Based on a review of client records on October 26-27, 2016, the facility failed to obtain an informed and voluntary consent to release information from the client in three of fifteen client records.Client #10 was admitted into treatment on 12/16/2015 and was discharged on 4/25/2016. A consent to release information for the urinalysis collected and submitted on 1/11/2016, 2/22/2016 and 4/11/2016 to Atlantic Diagnostic Laboratories was not obtained from the client.Client #12 was admitted into treatment on 12/16/2015 and was discharged on 5/16/2016. A consent to release information for the urinalysis collected and submitted on 2/22/2016, 3/28/2016, and 4/18/2016 to LabCorp was not obtained from the client.Client #13 was admitted into treatment on 1/7/2016 and was discharged on 7/25/2016. A consent to release information for the urinalysis collected and submitted on 2/4/2016, 2/11/2016, 2/16/2016, 2/23/2016, and 3/9/2016 to LabCorp was not obtained from the client. These findings were reviewed with facility staff during the licensing process.This is a repeat citation.The facility was previously cited for noncompliance of this standard during the September 30, 2015 licensing inspection.
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Plan of Correction
1. The facility will at intake have clients sign voluntary consent for laboratory services matching their in network provider.
2 The Clinical supervisor will complete chart audits monthly evaluating compliance starting 1/2017.
3. The Director of Outpatient Services and Clinical Supervisor are responsible for ensuring corrective action plan implemented.
4 The staff will be trained and educated on consenting for laboratory services matching provider network at time of admission on 12/13 by Clinical Supervisor.
5 The deficiency will be corrected by 1/2017.
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711.94 (g) LICENSURE Medical Assistance Provider Agreement
711.94. 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 fifteen client records on October 26-27, 2016, the facility failed to have a licensed physician sign off on Medical Assistance client's treatment plans and updates in four client records requiring a physician signature.Client # 2 was admitted to treatment on 2/15/2016 and is still an active client. The individual treatment plan dated 3/14/2016 and updates on 4/29/2016, 7/28/2016, and 9/28/2016 did not have a physician signature. Client #4 was admitted to treatment on 2/17/2016 and discharged on 4/18/2016. The individual treatment plan dated 3/15/2016 did not have a physician signature.Client #8 was admitted to treatment on 12/29/2015 and is still an active client. The individual treatment plan dated 1/15/2016 and updates on 3/15/2016, 4/6/2016, 6/6/2016, 8/6/2016 and 10/6/2016 did not have a physician signature.Client #10 was admitted to treatment on 12/16/2015 and discharged on 4/25/2016. The individual treatment plan dated 1/25/2016 and update on 3/21/2016 did not have a physician signature.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The facility will implement process for all Medical Assistance client treatment plans and updates to be reviewed and signed by physician.
2. The Clinical supervisor will complete chart audits monthly evaluating compliance starting 1/2017.
3. The Director of Outpatient Services and Clinical Supervisor are responsible for ensuring corrective action plan implemented.
4. The staff and physicians will be trained and educated on process standard of treatment plans and updates reviewed and signed by physician on 12/12.
5. The deficiency will be corrected by 1/2017.
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