INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18-19, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clem-Mar House, Inc. was found to be not 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection conducted on April 18-19, 2017, the facility failed to ensure that cold food was kept below 40 degrees.The side-by-side type refrigerator in the Great Room alcove was measured at 43 degrees.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Head Resident Manager contacted the appliance repair business on 4/19/17. The repairman came out and fixed the problem on 4/21/17. To ensure the freezers will remain at a constant temperature, the Head Resident manager will check the temperature once per week. Should the temperature not be below 40 degrees, he will call the repairman immediately and make a report to the clinical director. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Seven client records were reviewed on April 19, 2017. The facility failed to ensure another client's confidentiality by putting that client's demographic information, discharge summary and aftercare plan in client #3's record. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
A staff meeting was held on 05/10/17 by the Clinical Director detailing the area of non-compliance. The information in client number 3's record that belonged to another client (demographic information, discharge summary and aftercare plan) was placed into the correct client file by the clinical director. Clinical staff were instructed on the importance of accurate filing and the confidentiality regulations. The Clinical Team Lead will be responsible for examining files on a weekly basis to ensure accuracy. The Clinical Director will again review the files at discharge and will monitor the process. This was implmented on 05/10/11. |
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
Seven client records were reviewed on April 19, 2017. The facility failed to obtain a valid consent to release information in client records, #3, 4, 5, & 7.Client #3 was admitted on 2/2/17 and was an active client at the time of the licensing inspection. A consent to release to a treatment provider dated 2/2/17 was not signed by the client.Client #4 was admitted on 12/7/16 and was discharged on 2/5/17. A facsimile transmission to a government agency dated 12/29/16 was documented in the record, however there was no consent to release for this agency.Client #5 was admitted on 12/16/16 and was discharged on 2/3/17. A consent to release to a government agency dated 2/2/17 did not have documentation of the purpose of the disclosure. Additionally, a facsimile transmission dated 1/27/17 to a government agency was documented in the record, however there was no consent to release information to this agency.Client #7 was admitted on 12/16/16 and was discharged on 3/16/17. Two facsimile transmissions dated 1/4/17 and 2/7/17 to the same government agency were contained in the record however there was no consent to release information to this agency. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
A Staff meeting was held on 05/10/17 by the Clinical Director detailing the area of non-compliance. All clinicians were provided with a copy of 255.5 confidentiality regulations and each area was reviewed. For our newest clinician, the Team Lead will meet with her separately when any correspondence on a client is sent out to ensure there is a properly filled out consent for the information requested.The Team Lead will review counselor files on a weekly basis to ensure compliance in this area. To also address the issue, the counselor of record for client number 3 obtained a proper release for the treatment provider of the correspondence released on 4/19/17.The Release was promptly placed in the clients record. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the policy and procedure manual conducted on April 18-19, 2017, the facility failed to include policies to respond to the following unusual incidents.(2) Selling of illicit drugs on the premises.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director and Clinical Director will meet to develop a policy which meets the licensing regulation for this area of Unusual Incidents on 05/19/17. This will be presented for board approval at their meeting on 05/24/17. The Clinical Director will then present the policy to the staff and it will be in effect as of 06/01/17. The Clinical Director and Team Lead will monitor this area for staff compliance. The Clinical Director will monitor licensing alerts and DDAP bulletins on a regular basis for any policy changes. Should there be any changes, our policies will be updated to comply with the new regulations. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the policy and procedure manual conducted on April 18-19, 2017, the facility failed to include policies to respond to the following unusual incidents.(4) Significant disruption of services ...which closes the facility for more than one day.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director and Clinical Director will meet to develop a policy which meets the licensing regulation for this area of Unusual Incidents on 05/19/17. This will be presented for board approval at their meeting on 05/24/17. The Clinical Director will then present the policy to the staff and it will be in effect as of 06/01/17. The Clinical Director and Team Lead will monitor this area for staff compliance. The Clinical Director will monitor licensing alerts and DDAP bulletins for any policy changes. Should there be any changes, our policies will be updated to comply with the new regulations. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the policy and procedure manual conducted on April 18-19, 2017, the facility failed to include policies to respond to the following unusual incidents.(5) Theft, burglary, break in or similar incident at the facility.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director and Clinical Director will meet to develop a policy which meets the licensing regulation for this area of Unusual Incidents on 05/19/17. This will be presented for board approval at their meeting on 05/24/17. The Clinical Director will then present the policy to the staff and it will be in effect as of 06/01/17. The Clinical Director and Team Lead will monitor this area for staff compliance. The Clinical Director will monitor licensing alerts and DDAP bulletins on a regular basis for any policy changes. Should there be any changes, our policies will be updated to comply with the new regulations. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the policy and procedure manual conducted on April 18-19, 2017, the facility failed to include policies to respond to the following unusual incidents.(6) Event at the facility requiring the presence of police, fire or ambulance personnel. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director and Clinical Director will meet to develop a policy which meets the licensing regulation for this area of Unusual Incidents on 05/19/17. This will be presented for board approval at their meeting on 05/24/17. The Clinical Director will then present the policy to the staff and it will be in effect as of 06/01/17. The Clinical Director and Team Lead will monitor this area for staff compliance. The Clinical Director will monitor licensing alerts and DDAP bulletins on a regular basis for any policy changes. Should there be any changes, our policies will be updated to comply with the new regulations. |