INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 5-7, 2007 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 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 October 4, 2007.
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Plan of Correction
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709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records it was determined that the facility failed to consistently include the purpose for the release of information on the consent to release information form. Consent to release information forms filed in client records # 3, 4 and 5 did not have a clear statement of the purpose for the release of information stated. The total record sample consisted of five records.
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Plan of Correction
The release forms in the client records 3,4,5. had a purpose checked but was not specific enough. The facility will be in full compliance by October 1st, 2007. The plan of action to obtain compliance is that the clinical staff will attend an inservice in which they will review the release and detail the purpose of the release. The Teamleader and Assistant Project Director will be responsible for monitoring the releases and ensure that they are in compliance with all regulations. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of agency policy and documentation on medication storage area inspection forms, it was determined that the facility failed to conduct monthly inspections in accordance with agency policy for two of the last twelve months.
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Plan of Correction
The facility conducted monthly med room inspections. At the time of inspection the documentation for the monthly inspections was not found. The facility will be in full compliance October 1st, 2007. The Assistant Project Director will designate a binder in the medication room and continue to conduct monthly inspections with the resident managers. The Assistant Project Director will be responsible for the documentation to be completed in a timely manner. |
709.53(a)(7) LICENSURE correspondence
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(7) Client-related correspondence.
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Observations
Based on a review of client records it was determined that the facility failed to meet this regulation due to the lack of sufficient detail regarding verbal disclosures made during telephone conversations. Documentation related to verbal disclosures of client related information were not sufficiently detailed to permit a determination as to whether information released was within appropriate limits established by 4 Pa. Code Subsection 255.5(b). This was noted in reviews of 4 of 4 applicable client records, (#1, 2, 4 and 5).
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Plan of Correction
The disclosures being made were logged on the casemanagement update log in the client records, but did not include enough detail on the disclosures. The facility will be in full compliance by October 1, 2007. The clinical staff will have an manditory inservice on proper documentation regarding confidentiality. The Teamleader and Assistant Project Director will be responsible for montioring charts through QA to ensure clinical staff is documentating the calls correctly. |