INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 5 through February 7, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, My Sister's Place 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 and a plan of correction is due on February 29, 2008.
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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
Based on a review of administrative documents on 2/7/08, the facility failed to document a fire drill during sleeping hours at least every six months. The last fire drill conducted during sleeping hours was on 3/31/07.
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Plan of Correction
Although there are two recorded 8AM drills (8/2/07, 11/07/07), there were no drills at 6AM due to weather issues. However, early AM drills will be held in early Spring and and Fall to help reduce weather exposures to fragile infants and meet the standard.
Person(s) responsible: Residential Operations Director and the Chef (who is acting Fire Marshall, on-site)
Timeframe for compltion 2/10/08 |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of administrative documents on 2/7/08, the facility failed to document alternate exit routes to be used during fire drills. The women and children consistently use the fire tower exits during fire drills.
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Plan of Correction
To ensure mothers, children, and staff use all exits, practice drill will be held monthly that expand the use from the four generally used to the six existing exits. This will provide additional security and ease of egress for the entire community. The "Record of Fire Drill" has been revised to include all exits. The policy and procedure will reflect this new procedure as well as listing "sleeping times" for the facility to meet standards.
Person(s) responsible: Program Director and Residential Operations Director
Timeframe for Completion: 2/19/08 |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on 2/6/08, the facility failed to document a complete psychosocial evaluation in five of five client records reviewed, #1, 2, 3, 4 and 5. The evaluations did not include a clinical assessment of how assets/strengths, support systems and negative factors would impact the potential for treatment. Additionally, coping mechanism were missing in #2, 3 and 5.
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Plan of Correction
A training occurred immediately prior to the site visit addressing these citations. However, the Clinical Director is continuing on-going documentation trainings for all clinical staff. Trainings emphasize the importance of gathering complete, narrative intake data and assessment information in order to develop a clinical sound treatment plan. PSH will be reviewed on a monthly basis for all new admissions to insure completion. Any deficiencies will be immediately addressed and followed-up in weekly clinical supervison.
Person(s) responsible:
Clinical Director and Counselors
Timeframe for compltion: 2/18/08 |
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
711.53. 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 2/6/08, the facility failed to document an informed and voluntary consent from the client in five of five client records reviewed, #1, 2, 3, 4 and 5. The consent forms included language which allowed only for written revocation of the consents.
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Plan of Correction
An updated Consent Form, which includes language covering both written and verbal revocation of consent, has been distributed to all staff. Any old forms that were not previously destroyed, after correcting this citation in the past, have been discarded. Close monitoring throughout the intake/admission period , and in random monthly chart reviews, will help to insure the correct consent forms are being used.
Person(s) responsible: Clinical Director, Counselors, Administrative Asssitant
Timeframe for completions: 2/26/08 |
711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
711.53. 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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records on 2/6/08, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in five of five client records reviewed, #1, 2, 3, 4 and 5. The specific information to be disclosed to the Department of Public Welfare (DPW), probation and the Department of Human Services exceeded that allowed under 4 Pa. code 255.5 in three records, #1, 2 and 5. Consent to release information forms to DPW and the Fire Department/EMS did not identify the specific information to be disclosed in four records reviewed, #2, 3, 4 and 5.
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Plan of Correction
The Consent Form has been revised that specifically outlines who and what information may be released. A training has been scheduled for March to address the issues of adherence to 4Pa. Code 255.5 and how to implement the new form. This revised form should eliminate further deficiencies. Close monitoring throughout the intake/admission process and random monthly chart reviews will further assist in addressing compliance.
Person(s) responsible: Clinical Director, Primary Counselors, and Administrative Assistant
Timeframe for completion: 3/14/08 |
711.53(c)(2)(iii) LICENSURE Purpose of Disclosure
711.53. 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:
(iii) The purpose of disclosure.
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Observations
Based on a review of client records on 2/6/08, the facility failed to obtain an informed and voluntary consent from the client in three of five client records reviewed, #1, 3 and 4. Consent forms did not include the purpose for the release of information.
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Plan of Correction
The Consent Form has been revised that specifically outlines the purpose for any information being released. A training has been scheduled for March to address the issues of adherence to 4Pa. Code 255.5 specific purpose for disclosure. This revised form should eliminate further deficiencies. Close monitoring throughout the intake/admission process and random monthly chart reviews will further assist in addressing compliance.
Person(s) responsible: Clinical Director, Primary Counselors, and Administrative Assistant
Timeframe for completion: 3/14/08 |
711.53(c)(2)(vi) LICENSURE Consent's Expiration Date
711.53. 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:
(vi) The expiration date of the consent.
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Observations
Based on a review of client records on 2/6/08, the facility failed to obtain an informed and voluntary consent from the client in two of five client records reviewed, #3 and 4. Consents to release information to the Department of Public Welfare (DPW) and Community Behavioral Health (CBH) did not include an expiration date.
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Plan of Correction
A training has been scheduled in March to address the issues of adherence to 4Pa. Code 255.5 and the legal issues of including expiration dates. Close monitoring throughout the intake/admission process and random monthly chart reviews will further assist in addressing compliance.
Person(s) responsible: Clinical Director, Primary Counselors, and Administrative Assistant
Timeframe for completion: 2/11/08 |
711.58(a)(3) LICENSURE Inspection of Storage Area
711.58. Medication control.
When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of administrative documents on 2/7/08, the facility failed to document quarterly inspections of medication storage areas. The last inspection documented was in September 2007.
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Plan of Correction
The Clinical Director and Family Center Nurse will complete, and document, an inspection for the 3rd Quarter. Upon hiring a nurse, this task will be complete this task on a quarterly basis. The Clinical Director will review, and sign, the Inspection of Medication Storage book on a quarterly basis. The new hire will receive training from the Nurse Manager at Family Center regarding the correct procedures.
Person(s) responsible: Clinical Director, Nurse Manager,and Lead Hous Manager
Timeframe for completion: 3/8/08 |