INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 27-29, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute, 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel and training records, the facility failed to provide documentation of communicable disease training in one of two personnel records reviewed.
The findings include:
Two personnel records requiring documentation of mandatory communicable disease training were reviewed on 10/27/2014. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employee # 4.
Employee # 4 was hired on 8/26/2013 as a counselor. This employee was required to obtain six hours of HIV/AIDS and four hours of TB/STD training by 8/26/2014. Employee # 4 failed to obtain the training as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Counselor who did not complete 4 hours of TB, STD and other health topics and 6 hours of HIV/AIDS completed both trainings 11/4 and 11/5/2014. In order to avoid future training delays, St Joseph Institute will assign a staff member to provide this training in house every 6 months. All new hires will be scheduled to take the course during the next 6 months to assure all staff meet requirements. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on the physical plant inspection, the facility failed to ensure that the water temperature did not exceed 120 degrees.
The findings include:
A physical plant inspection was conducted on 10/29/2014 at approximately 11:00 AM.
The hot water temperature at the bathroom sink in Room 1 on the first floor of the Spruce Building was recorded at 131.9 degrees Fahrenheit.
The hot water temperature at the bathroom sink in Room B on the second floor of the Spruce Building was recorded at 126.3 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Installer of the water system in Spruce Lodge is rebuilding the system to ensure water temperature remains below 120 degrees. This work should be completed by November 24. The Maintenance Supervisor will continue monthly monitoring to assure proper water temperature. |
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of client records, the facility exceeded the limitations imposed in 4 Pa. Code, Subsection 255.5(b) as it pertains to the information authorized to be released per the the informed and voluntary to release information forms in three of ten client records reviewed.
The findings include:
Limitations imposed at 4 Pa. Code, Subsection 255.5(b) specify that the release of information to probation officers and insurance companies shall be restricted to whether the client is or is not in treatment, the prognosis of the client, the nature of the project, a brief description of the progress of the client, and a short statement as to whether the client has relapsed and the frequency of such relapse.
Ten client records requiring informed and voluntary consent to release information forms were reviewed on 10/27/2014 and 10/28/2014. The facility failed to ensure that the informed and voluntary consent to release information forms only authorized the release of information as per the restrictions within 4 Pa. Code, Subsection 255.5(b) in client records 4, 7 and 8.
Client # 4 was admitted on 7/1/2014. Client # 4's informed and voluntary consent to release information to the client's probation officer dated 7/1/2014 authorized the release of the client's medical history, insurance and payment information, legal charges and disposition, aftercare recommendations, and tests and treatments provided at the facility.
Client # 7 was admitted on 9/10/2014. Client # 7's informed and voluntary consent to release information to the client's insurance provider dated 9/10/2014 authorized the release of the client's alcohol/drug history, diagnostic impressions, symptomology, biographical history, family history, psychological history, social history, evaluation results and recommendations, discharge summary, aftercare recommendations, urinalysis results, breathalyzer results, lab results, and chiropractic and physical therapy care.
Client # 8 was admitted on 9/24/2014. Client # 8's informed and voluntary consent to release information to the client's insurance provider dated 9/24/2014 authorized the release of the client's alcohol/drug history, diagnostic impressions, symptomology, biographical history, family history, psychological history, social history, evaluation results and recommendations, discharge summary, aftercare recommendations, urinalysis results, breathalyzer results, lab results, and chiropractic and physical therapy care.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Release of information forms have been updated to include authorization to "release" or "obtain" as separate selections. This updated form was implemented November 3, 2014 Staff will be trained by November 15, 2014 regarding PA Code 255.5(b) and limitations to voluntary consent with regard to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials. The Compliance Officer will review records monthly, beginning November 15 to assure proper completion of forms. |
715.12(1-5) LICENSURE Informed patient consent
A narcotic treatment program shall obtain an informed, voluntary, written consent before an agent may be administered to the patient for either maintenance or detoxification treatment. The following shall appear on the patient consent form:
(1) That methadone and LAAM are narcotic drugs which can be harmful if taken without medical supervision.
(2) That methadone and LAAM are addictive medications and may, like other drugs used in medical practices, produce adverse results.
(3) That alternative methods of treatment exist.
(4) That the possible risks and complications of treatment have been explained to the patient.
(5) That methadone is transmitted to the unborn child and will cause physical dependence.
|
Observations
Based on a review of client records, the facility failed to obtain an informed, voluntary, written consent prior to the administration of a narcotic agent for detoxification treatment in two of two client records reviewed.
The findings include:
Two client records requiring informed, voluntary, written consent to treatment prior to the administration of a narcotic agent were reviewed on 10/28/2014. The facility failed to document the completion of an informed, voluntary, written consent that includes the required content specified in prior to the administration of the narcotic agent Suboxone in client records # 9 and 10.
Client # 9 was admitted into treatment on 8/12/2014. The client received his/her initial dose of Suboxone on 8/12/2014 at 6:48 PM. There was no documentation of an informed, voluntary, written consent for Suboxone treatment in client record # 9.
Client # 10 was admitted into treatment on 8/18/2014. The client received his/her initial dose of Suboxone on 8/19/2014 at 11:15 AM. There was no documentation of an informed, voluntary, written consent for Suboxone treatment in client record # 10.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
A separate informed consent form has been developed which includes the 5 required notifications. This form was implemented November 3, 2014 This form shall be reviewed with every resident and signed off by resident prior to beginning Suboxone treatment for detoxification. Compliance Officer will review records monthly to assure informed consent signed for each resident receiving Suboxone treatment.
|