INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Gateway Rehabilitation Center Inc, Moffett House 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) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to conduct a fire drill during sleeping hours at least once every six months for fire drill logs reviewed on October 17, 2017.
The fire drill logs were reviewed from October 2016 to September 2017. An overnight fire drill was conducted on February 22, 2017. The next overnight fire drill was conducted on September 22, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The manager of facility will schedule at least 1 overnight fire drill every six months. Upon completion of overnight fire drill an email will be sent out through Gateway's D-3 system to facility manager & director. Facility director will semi-annually review fire drills through D-3 report to ensure that drill is being completed in timely fashion. |
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
The facility failed to obtain an informed and voluntary consent to the funding source for the disclosure of client information in seven of seven client records reviewed on October 17, 2017.
Releases of information to the funding source failed to include the name/agency/organization to whom the information would be disclosed in client records # 1, 3, 5, 6 and 7.
The facility failed to document compliance with Pa Code 255.5. The facility documents on the Assignment of Benefits form that the facility's President/Chief Executive Officer has the authority to approve the release of additional information to the insurance company if necessary to process claims. This is incorrect; the information released to the funding source is limited to the information outlined in Pa Code 255.5. This statement was documented in client records # 1, 2, 3, 4, 5, 6 and 7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The release of information to an insurance company shall specify the insurance company and limit the release of information to the following:
Whether the client is or is not in treatment; The prognosis of the patient; the nature of the project; a brief description of the progress of the patient; a short statement as to whether the patient has relapsed into drug and alcohol abuse and the frequency of such relapse.
The Director of Health Information Management educated all applicable staff to this revision through electronic communication on November 1, 2017
The Director of Health Information Management will conduct admission chart audits (after each client admission) to ensure compliance with the Consent for Insurance and, in turn will share audit results with Program Directors.
The Assignment of Benefits form was revised to include the following statement:
"In the event that an insurance company, health, or hospital plan remains dissatisfied with the content of the information released with regard to a client in accordance with this paragraph, such insurance company, health or hospital plan may apply to the State Level Executive Director for additional information, upon approval by the Executive Director, such information may be released."
In turn, the Director of Health Information Management educated all applicable staff to this revision through electronic communication also on November 1, 2017
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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
The facility failed to document that clients were informed of all the required client rights in seven of seven client records.
Three client handbooks (Residential, Youth and Outpatient) were reviewed on October 11-13, 2017. Client records were reviewed on October 17, 2017. The clients sign a form acknowledging the receipt of the handbook. None of the three handbooks presented contained all of the required client rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All handbooks were and will be reviewed by program Directors and modified to ensure proper documentation of client rights according to DDAP regulation 709.30. For the handbooks that were previously printed, the Director of each program and/or location will ensure that each hand book has an addendum with the updated client rights. Addendums were printed and distributed to program Directors/Managers November 15, 2017
The "Patient Treatment Agreement" form already exists and provides a signed acknowledgement of receipt of the patient handbook.
As directed by the Program Director, the facility's Admissions Officers/ Assistants will order the printed patient handbook as supplies are needed and will ensure that the correct version of the patient rights is included in the handbook.
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