INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16-18, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, The Ranch Pennsylvania 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill log for the period of March 2019 through November 2019, the facility failed to document what exits were used during the fire drills.
The facility fire drill log had had a place to document the exits used for the drills; however, some months had nothing documented for exits used.
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Plan of Correction
A training workshop session was held by Quality Assurance Coordinator on January 3, 2020 to refresh the Operations Department on the completion of the fire/emergency drill documentation to ensure compliance with fire safety requirements.
Monthly audits shall be conducted on the fire/emergency drill documentation to ensure the proper completion of the drill and the accompanying paperwork. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill log for the period of March 2019 through November 2019, the facility failed to document what exits were used during the fire drills.
The facility fire drill log had had a place to document the exits used for the drills; however, some months had nothing documented for exits used.
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Plan of Correction
A training workshop session was held by Quality Assurance Coordinator on January 3, 2020 to refresh the Operations Department on the completion of the fire/emergency drill documentation to ensure compliance with fire safety requirements.
Monthly audits shall be conducted on the fire/emergency drill documentation to ensure the proper completion of the drill and the accompanying paperwork. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client records and client related correspondences, the facility failed to adhere to 4 Pa. Code 255.5(b) regarding information released to the funding source in two of seven client records reviewed.
4 Pa. Code 255.5(b) Restrictions - states the following:
(b) Information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
Client # 3 was admitted to the facility on 11/19/2019 as a detox patient and was later stepped down to the residential level of care on 12/11/2019 and is still an active client. At the time of the inspection it was noted that information released in correspondence with the funding source exceeded what is permitted per 4 Pa. Code 255.5(b). The facility release included documentation of a medication, documentation of the drugs/pattern of use, marital status vitals from physical.
Client #7 was admitted to residential treatment on 10/21/2019 and discharged on 11/20/2019. At the time of the inspection it was noted that information released in correspondences with the funding source exceeded what is permitted per 4 Pa. Code 255.5(b). The facility released the following documents to the funding source:
1. Nursing Admission Assessment - dated 10/21/2019
2. Psychiatric Admission Evaluation - dated 10/22/2019
3. Biopsychosocial Histories/Assessment and Interpretive Summary - dated 10/22/2019
4. Brief Clinical Note - dated 10/22/2019
5. Doctor's Orders - dated 10/23/2019
5. Aftercare plan - dated 11/19/2019
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Plan of Correction
The Corporate Medical Records Administrator has scheduled a training workshop session with the facility Quality Assurance and Utilization Review staff the week of January 13th to review procedures and requirements for confidential information and the state and federal restrictions on same.
The Utilization Review Manager and Quality Assurance Coordinator shall complete weekly audits of confidential information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials to ensure compliance with state and federal confidentiality rules and regulations. |