INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on March 12 and 13, 2008, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Lehigh Valley Drug and Alcohol Intake Unit 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 April 11, 2008.
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Plan of Correction
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based on the client record review completed during the onsite licensing inspection, the facility failed to consistently document release of information to government entities (Northampton Co. SCA and Probation) which were within the parameters of 4 Pa. Code subsection 255.5(b). Client records # 5, 6, 7, 8,10 and 11 contained consents to release information which would permit the psychosocial evaluations to be released to these agencies. Specific information to be released was not stated on one consent in client record # 4. The record sample consisted of eleven records.
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Plan of Correction
Clinical Director will meet with Assessment staff by 4/30/08 to provide an in-service on the proper completion of the Release of Information to include specific information to be released. Clinical Director will monitor for compliance for the first six months starting 5/1/08 then quarterly. Clinical Director will provide outcome data to the Quality Assurance committee on a quarterly basis.
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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 shall be in writing and include, but not be limited to:
(6) Expiration date of the consent.
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Observations
Based on the client record review conducted during the onsite licensing inspection of March 12 and 13, 2008, the facility failed to execute consent forms which contained an expiration date or event for the release of information form to expire. This occurred on the Northampton County SCA consent to release information form executed by agency staff in client records # 3, 4, 6, 7, 8 and 9. The record sample consisted of eleven client records.
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Plan of Correction
Clinical Director will meet with Assessment staff by 4/30/08 to provide an in-service on the proper completion of the Release of Information focusing on the Release Date or event for the release of information form to expire. Clinical Director will monitor for compliance for the first six months starting 5/1/08 then quarterly. Clinical Director will provide outcome data to the Quality Assurance committee on a quarterly basis.
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on the physical plant inspection held March 12, 2008, the facility failed to maintain bathrooms with working exhaust fans. Neither the men's or women's bathrooms had a window or a working exhaust fan at the time of this inspection.
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Plan of Correction
Executive Director will contact the landlord alerting of the compliance issue and encourage him to rectify the situation. Letter to be sent by 4/30/08. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of fire drill documentation of the past year, in the logs presented at the time of the onsite inspection of March 12 and 13, 2008, the facility failed to document the use of alternate exit routes during fire drills at any time in the past 12 month period.
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Plan of Correction
Clinical Director will be instructed (memo by the Executive Director) to assure that one in four fire drills will use an alternative route. Executive Director will monitor fire drill reports for compliance. The first to be conducted by July 1,2008. |
709.44(a)(1)(iii) LICENSURE Personal history
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(1) Histories, which include the following:
(iii) Personal history.
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Observations
Based on the review of client records during the onsite licensing inspections held March 11 and 12, 2008, the facility failed to document personal histories which addressed specific family relationship issues and dynamics in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. Employment histories did not give details on jobs held, dates of employment or the impact of D&A use on client employment in client records #1, 2, 3, 4, 5, 6, 7, 8, 9, 10 and 11. The total record sample reviewed was eleven client records.
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Plan of Correction
Clinical Director and Administrative Case mgr. will review deficiencies in completion of the Assessment tool with the Assessment staff by 3/31/08. Clinical Director will in-service Assessment staff on the proper method of completing the Evaluation tool by 3/31/08. Files will be monitored on a monthly basis for compliance for the first three months. Quarterly random reviews will be conducted following this time by the Clinical Director, Administrative Case Mgr. and Executive Director. Results will be presented to the Quality Assurance Committee for review to assure compliance. |
709.44(a)(3) LICENSURE Psychosocial evaluation
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(3) Psychosocial evaluation.
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Observations
Based on the client record review during the onsite licensing inspection held March 12 and 13, 2008, the facility failed to document psychosocial evaluations which addressed support systems available to assist the client in recovery efforts (client records # 1, 2 and 7). Coping mechanisms (denial, rationalization, minimizing, repression, etc.) were not addressed in client records # 2, 3, 4, 5 or 8. The sample was eleven client records.
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Plan of Correction
Clinical Director and Administrative Case mgr. will review deficiencies in completion of the Psychosocial evaluations with the Assessment staff by 3/31/08. Clinical Director will in-service Assessment staff on the proper method of completing the psychosocial evaluation by 3/31/08. Files will be monitored on a monthly basis for compliance for the first three months. Quarterly random reviews will be conducted following this time by the Clinical Director, Administrative Case Mgr. and Executive Director. Results will be presented to the Quality Assurance Committee for review to assure compliance |