INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 7, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Conewago - Pottsville 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of the Staffing Requirements Facility Summary Report and personnel records, there was no documentation that 3rd shift staff had CPR or First Aid certification between May 29, 2022 and July 2, 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CPR and First Aid trainings were conducted on 7/8/2022 and 7/14/2022. The Facility Director shall ensure that at least one staff trained in these skills is on-site at all times during the program'24/7 hours of operation. Compliance with this standard was obtained on 7/14/2022. The Facility Director, as well as the Corporate Training Officer and the Corporate Compliance Officer shall monitor compliance on an on-going basis beginning 7/22/2022. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.Client #2 was admitted on November 30, 2021 and discharged Against Medical Advice (AMA) on December 7, 2021. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
The AMA (Against Medical Advise) discharge policy was revised and approved by the Firetree, Ltd. governing body to address AMA notification processes. The Facility Director is responsible for ensuring the corrective actions are properly implemented. Specific steps to ensure that the client's emergency contact is contacted within 12 hours of an AMA discharge include the following:
- Contact is made to Facility Director, Clinical Director, and COO regarding a client's ideation or AMA occurrence.
- The Facility Director is responsible for ensuring the client's emergency contact has been notified of the AMA by trained staff within 12 hours of the AMA occurrence.
- An AMA checklist is utilized that includes documented confirmation that notification was made to the AMA client's emergency contact.
- The completed AMA checklist is a required attachment to the Firetree, Ltd. internal e-mail grouping that notifies applicable Firetree staff of an AMA occurrence.
- Program staff were trained on the new AMA emergency contact process on 7/20/22, and on-going training to new staff is ensured by the addition of the AMA emergency contact topic to the new hire on-boarding training agenda.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of six personnel records, the facility failed to ensure that employees have annual written individual staff performance evaluations signed by the employee in one of one applicable record reviewed. Employee #1 has been in the position of Project Director since June 28, 2020. The record contained no documentation of an annual performance evaluation. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 7/22/2022 Firetree, Ltd.'s Human Resource Department shall track the performance evaluation due dates, and ensure the completion of the Project Director's performance evaluations. The Project Director position is currently vacant and a performance evaluation will be completed on the new Project Director within 6 months of filling the vacancy, and annually thereafter. |
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
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in six records reviewed. Client #1 was admitted on March 16, 2022 and was discharged on April 25, 2022. The record contained documentation that personal identifying information was released to the Department of Human Services on April 15, 2022 and April 1, 2022, with no consent to release information form signed by the client. Client #2 was admitted on November 30, 2021 and was discharged on December 7, 2021. The record contained documentation that personal identifying information was released to the Department of Human Services on December 1, 2021, with no consent to release information form signed by the client. Client #3 was admitted on December 15, 2021 and was discharged on January 21, 2022. The record contained documentation that personal identifying information was released to the Department of Human Services on January 14, 2022, with no consent to release information form signed by the client. Client #5 was admitted on June 8, 2022 and was active at the time of the inspection. The record contained documentation that personal identifying information was released to the Department of Human Services on July 1, 2022, with no consent to release information form signed by the client. Client #6 was admitted on June 8, 2022 and was active at the time of the inspection. The record contained documentation that personal identifying information was released to the Department of Human Services on July 1, 2022, with no consent to release information form signed by the client. Client #7 was admitted on June 10, 2022 and was active at the time of the inspection. The record contained documentation that personal identifying information was released to the Department of Human Services on July 1, 2022, with no consent to release information form signed by the client. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/20/2022, the Clinical Supervisor conducted a comprehensive training on the topic of informed and voluntary consents from the clients for disclosure of information. Emphasis was placed on the consent expiration dates and types of consents required. The Clinical Supervisor will provide by 8/31/2022 additional and continued trainings to all clinical staff regarding appropriate completion of consents. The Corporate Compliance Department will monitor the compliance of consent documentation as part of scheduled client chart audits beginning 7/22/2022. Consents for release of information to the Department of Human Services have been completed on all applicable clients as of 7/20/2022. |
709.28 (c) (6) 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 must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the date, event, or condition upon which the consent will expire in three records reviewed.Client #1 was admitted on March 16, 2022 and was discharged on April 25, 2022. The record contained consent to release information forms to an attorney and a county agency signed by the client on March 29, 2022 and March 23, 202, respectively, that were missing the date, event, or condition upon which the consent will expire.Client #4 was admitted on July 6, 2021 and was discharged on August 12, 2021. The record contained consent to release information forms to the funding source, emergency contact, and parole agent signed by the client on July 13, 2021 that were missing the date, event, or condition upon which the consent will expire.Client #5 was admitted on June 8, 2022 and was active at the time of the inspection. The record contained consent to release information forms to a cell phone company signed by the client on June 29, 2022 that was missing the date, event, or condition upon which the consent will expire.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/20/2022, the Clinical Supervisor conducted a comprehensive training on the topic of informed and voluntary consents from the clients for disclosure of information. Emphasis was placed on the proper documentation of consent expiration dates and the types of consents required. The Clinical Supervisor will provide by 8/31/2022 additional and continued trainings to all clinical staff regarding appropriate completion of consents. The Clinical Supervisor and Corporate Compliance Department will monitor consent documentation compliance as part of scheduled client chart audits beginning 7/22/2022. Consents for release of information that include documented consent expiration dates in all current clients are present as of 7/20/2022 |