INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on October 4 and 5, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based upon the review of the fire drill records, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.The findings include:The fire drill records for October 2011 to September 2012 were reviewed on October 5, 2012. The facility hours are posted as Monday through Friday 5:30 a.m. to 6 p.m., Saturday 6 a.m. to 11 a.m. and Sunday 7 a.m. to 8:30 a.m. The facility failed to conduct fire drills between the hours of 5:30 a.m. and 11:00 a.m. when many patients are being treated by the facility. The hours of 3 p.m. to 6 p.m. were not documented in the fire drill record when second shift staff are present.The findings were reviewed with the facility director, project director, clinical supervisor, medical and clinical staff and were not disputed.
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Plan of Correction
The staff member who schedules and records fire drills has been advised of the need to randomize the time of day that such drills are conducted. The Program Director will review the log book associated with this activity and insure that this protocol is followed. |
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:
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Observations
Based on the review of patient records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in five of seven patient records reviewed. The facility exceeded 4 Pa. Code, Subsection 255.5(b) in one of seven records reviewed. The findings included:Seventeen patient records were reviewed October 4 and 5, 2012. Seven records were reviewed regarding release of information documentation. The facility failed to ensure that an informed and voluntary consent to release information was obtained in five patient records reviewed, # 11, 12, 13, 14 and 15. The facility exceeded 4 Pa. Code, Subsection 255.5(b) in one patient record reviewed, #16.A review of patient record # 11 revealed information was released to a funding source on August 22, 2012. The patient signed a consent to release information on August 30, 2012. The patient did not sign a release prior to releasing information to the funding entity. A review of patient record # 12 revealed information was released to a funding source on July 19, 2012. The patient signed a consent to release information on July 23, 2012. The patient did not sign a release prior to releasing information to the funding entity. A review of patient record # 13 revealed information was released to a funding source on May 7, 2012. The patient signed a consent to release information on May 18, 2012. The patient did not sign a release prior to releasing information to the funding entity.A review of patient record # 14 revealed information was released to a funding source on January 24, 2012. The patient signed a consent to release information on February 13, 2012. The patient did not sign a release prior to releasing information to the funding entity.A review of patient record # 15 revealed information was released to a funding source on April 18, 2012. The patient signed a consent to release information on April 27, 2012. The patient did not sign a release prior to releasing information to the funding entity.A review of patient record # 16 revealed a consent to release information to a parole officer. A letter sent to the parole officer disclosed the patient medication by name, plans for dosing and detoxification. The facility exceeded 4 Pa. Code, Subsection 255.5(b) by releasing information to the parole officer that included type and frequency of treatment and type of medication. The findings were reviewed with the facility director, project director, clinical supervisor, medical and clinical staff and were not disputed.
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Plan of Correction
The reference to patient records 11, 12, 13, 14 and 15 were all the same situation in which an applicant, usually calling on the phone, claiming to be an active Medicaid subscriber, provided a date of birth and social security number that was then used to verify their active status on the PA Promise system. The consent form referenced in this citation that was signed later, at time of admission, was intended for billing for services subsequent to admission. We have amended our procedure to make inquiries on the Promise system at the time of the assessment after the patient has signed a consent specifically for the purpose of making such inquiries. The staff members who take calls from applicants have been so advised and compliance with this requirement will be monitored by the Clinical Supervisor in the future.
Subsequent to the site visit, the counselor who had sent the letter to the parole officer in regard to patient #16 was reminded that restrictions in 255.5(b)(1) ? (5) do not permit the release of such information. The rest of the counseling staff was given similar reminders. Going forward the Clinical Supervisor will address this issue in periodic chart reviews.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of patient records, the facility failed to document in the treatment plan update the patient's progress as it relates to the goals identified in the individualized treatment and rehabilitation plan in three of four patient records.The findings include:Seventeen patient records were reviewed October 4 and 5, 2012. Four of the seventeen patient records were required to have a treatment plan update. Three patient records did not include documentation of a treatment plan update with progress on identified goals, # 13, 14, and 15.Patient # 13 was admitted on May 18, 2012. An individual treatment and rehabilitation plan was documented on June 15, 2012. A treatment plan update was documented on August 15, 2012. The treatment plan update did not include progress of the goals identified on June 15, 2012. Patient # 14 was admitted on February 13, 2012. An individual treatment and rehabilitation plan was documented on February 13, 2012. A treatment plan update was documented on May 22, 2012, that was not signed by the patient. This update was due by April 13, 2012. A treatment plan update was documented on July 16, 2012. A treatment plan update was documented on September 26, 2012, and not signed by the patient. This update was due by September 16, 2012. The treatment plan updates did not include progress of the goals identified in the previous treatment plans. Patient # 15 was admitted on April 30, 2012. An individual treatment and rehabilitation plan was documented on May 21, 2012. Treatment plan updates were due by July 21, 2012 and September 21, 2012. At the time of the review, no treatment plan updates were documented in the record. The findings were reviewed with the facility director, project director, clinical supervisor, medical and clinical staff and were not disputed.
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Plan of Correction
The citations regarding this standard have been discussed in detail with the two counselors involved. The have been advised of the necessity of reviewing progress on goals from the prior plan and producing properly signed updates on time. The Clinical Supervisor will be responsible for monitoring compliance. The chart reviews that are currently done with charts from all members of the counseling staff, will focus on these counselors in particular with an emphasis on insuring compliance with this standard. |