INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 28, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, A Better Today, Inc. was found to not 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(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
The facility failed to collect feedback on completed trainings in two out of five staff records reviewed. Staff #1 was hired on October 1, 1987 as Project Director and Facility Director had no feedback forms for trainings attended in the 2017 training year. Staff #2 hired on October 17, 2015 and currently in the role of Clinical Director, had one feedback form with no date or topic listed on the form. Staff #2 had no other feedback forms for the training year 2017. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
In accordance with 704.11 the Clinical Director will ensure that documentation of training certificates and collecting feedback on completed trainings is completed in each employee file within one week from the day of training. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
The facility failed to conduct fire drills on different days of the week. In fire drills documented from November 2017 to October 2018, five of twelve fire drills were completed on Tuesdays and five of twelve fire drills were completed on Wednesdays. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 705.10 the assistant clinical director in conjunction with the lead counselor will conduct fire drills on different days of the week, at different times of the day and night as well on different staffing shifts. Appropriate documentation, which includes the date, time, amount of time it took for evacuation, the exit route used, the number of persons at the facility at the time of drill, problems encountered and whether the fire alarm and smoker detector was operative will be completed and filed in the Fire drill Log the date the drill is completed. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to obtain the name of the person, agency or organization to whom disclosure is made when obtaining consent. Client #9 had an Intake, Evaluation and Referral completed on April 4, 2018. There was a consent that was signed and witnessed on April 4, 2018 missing the name of the person, agency or organization to whom the disclosure was made. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 709.28 the clinical staff was educated on confidentiality and the importance of completing a release for any third party disclosure, which includes Name of the person, agency or organization to whom disclosure will be made.
Monthly training will include how to properly complete a release of information.
Weekly Quality Insurance will be performed to insure completion of required documentation and releases are completed.
Clinical Director is responsible for this implementation and continued education.
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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 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
The facility failed to recognize the condition upon which consents will expire as provided for under 42 CFR in twelve out of fourteen records. Client #1 was admitted to outpatient on February 27, 2018 and was still active at the time of the inspection. A signed consent to a doctor dated February 27, 2018 specified that revocation of consent could only be made verbally or in writing to their counselor. Client #2 was admitted to outpatient on June 22, 2018 and was still active at the time of the inspection. A signed consent to a mental health provider and a MAT provider dated October 22, 2018, specified revocation of consents could only be made verbally or in writing to their counselor. Client #3 was admitted to outpatient on March 6, 2018 and was still active at the time of the inspection. A signed consent to children and youth services dated March 6, 2018 and April 4, 2018 specified revocation of consents could only be made verbally or in writing to their counselor. Client #4 was admitted to outpatient on December 20, 2017 and discharged on February 23, 2018. A signed consent to probation dated December 20, 2017 specified revocation of consent could only be made verbally or in writing to their counselor. Client # 5 was admitted to outpatient on December 20, 2017 and was discharged on May 11, 2018. A signed consent to probation, a township, and a driver resource center dated December 29, 2017 specified revocation of consents could only be made verbally or in writing to their counselor. Client # 6 was admitted to outpatient on December 29, 2017 and was discharged on June 1, 2018. A signed consent to probation dated December 29, 2017 specified revocation of consent could only be made verbally or in writing to their counselor. Client #7 was admitted on January 18, 2018 and discharged on June 20, 2018. A signed consent to children and youth dated January 18, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client #8 had an Intake, Evaluation and Referral on August 9, 2018. A consent to municipal court and an attorney dated August 9, 2018 specified revocation of consents could only be made verbally or in writing to their counselor. Client # 10 had an Intake, Evaluation and Referral on November 12, 2018. A signed consent to an attorney dated November 12, 2018 specified revocation of consents could only be made verbally or in writing to their counselor. Client # 11 had a Intake, Evaluation and Referral on January 22, 2018. A signed consent to mother and probation dated January 22, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client # 12 had an Intake, Evaluation and Referral on January 2, 2018. A signed consent to an attorney dated January 2, 2018 specified revocation of consent could only be made verbally or in writing to their counselor. Client # 14 had an Intake, Evaluation and Referral on May 21, 2018. A signed consent to probation and a doctor dated May 21, 2018 specified revocation of consents could only be made verbally or in writing to their counselor. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with 709.28 the Clinical Director has already updated consents as of 11/3/2018 to recognize the conditions upon which consents will expire as provided for under 42 CFR. The consents have been updated to reflect that consents at any time may be revoked by notifying any counselor, support staff or administrator verbally or in writing, except to the extent that action has been taken in reliance on my consent. |