INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 5-8, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Miners Medical 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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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 ensure that all of its clients were informed of their client rights. A total of twenty two client records were reviewed during the on-site inspection including three intake, evaluation and referral records. Clients #1, #2 and #3 were the intake evaluation and referral clients. None of the intake, evaluation and referral records contained written documentation from the clients that they had been notified of the following client 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. (2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. (3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. (4) Clients have the right to appeal a decision limiting access to their records to the director. (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. (6) Clients have the right to submit rebuttal data or memoranda to their own records.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
709.30 Licensure Client Rights:
The facility failed to comply with regulation 709.28 relating to Client Rights. On December 10th, 2018 the facility director will provide an in-house training to clinical staff members to ensure clients are informed of their client rights upon admission into the program. It is the responsibility of the Clinical Supervisor to ensure that compliancy with all client rights regulation is maintained through on-going training's and chart reviews during supervision. The Lead Counselor also will review that compliancy is maintained during weekly chart audits.
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709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
On November 5, 2018, at the time the inspectors arrived the first day of the on-site inspection, the facility did not have the hours of operation displayed conspicuously to the general public. These findings were discussed with facility staff as part of the inspection process.
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Plan of Correction
709.94(b) Licensure Project Management Services:
The facility failed to comply with 709.94 relating to Project Management Services. On November 5th, 2018 the facility director posted the hours of operation on display to the general public. It is the responsibility of the Health and Safety Officer to ensure it remains posted.
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709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
On November 5, 2018, at the time the inspectors arrived the first day of the on-site inspection, the facility did not have an emergency phone number displayed conspicuously to the general public. These findings were discussed with facility staff as part of the inspection process
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Plan of Correction
709.94(c) Licensure Project Management Services:
The facility failed to comply with 709.94 related to Project Management Services. On November 5th, 2018 the facility director posted the emergency phone number contact list on display to the general public. It is the responsibility of the Health and Safety Officer to ensure it remains posted.
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