Observations
Based on an inspection of the facility's physical plant, the facility failed to ensure that all exits from the facility were unobstructed.The findings include:A physical plant inspection was conducted on August 3, 2015 at around 2:35 PM. During the inspection it was found that the exit, from the courtyard in the rear of the building had exposed and unsecured utility wire hanging directly outside of the metal gate. It would not be possible to fully open the gate and leave the premises without contact with the wire. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Unfortunately the wires are outside our gates, therefore we are exploring who is responsible to fix the hanging wires. The facility director assumed that the utility wires belonged to PECO so a phone call was placed to their emergency line on August 3 where a technician was immediately sent. They discovered that the wires were not their property and they could not do anything about the hanging wires. We contacted Verizon and Comcast regarding the issue. After a period of going back and forth between companies Comcast has informed us that they will most likely fix the problem. The facility director will follow up with the company that finally fixes the problem to make sure it does not happen again. |
Observations
Based on a review of client records, the facility failed to obtain an informed consent prior to the disclosure of information contained in the client record. Additionally, when consent was obtained, the facility released information that exceeded what was permissible by 4Pa. Code 255.5(b).The findings include:Ten client records requiring consents to release information were reviewed on August 3, 2015. Information was released from four out of ten client records without a signed consent; specifically client records #2, 3, 4, and 9. Two out of ten client records reviewed contained signed consents that allowed for the release of information that exceeded that which is permissible to be released by 4Pa. Code 255.5(b) specifically records # 7 and 9.4 Pa. Code states:Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.(1) Whether the client is or is not in treatment.(2) Client's prognosis.(3) The nature of the project.(4) A brief description of the client's progress.(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.Client # 2 was admitted into treatment on 5/29/15 and was still active at the time of inspection. Client identifying information was released to a laboratory on 6/5/15, 6/10/15, 6/17/15, 7/2/15, and 7/24/15. There was no documentation of a signed consent for the laboratory in client record # 2. Client # 3 was admitted into treatment on 4/27/15 and was still active at the time of inspection. Client identifying information was released to a laboratory on 5/13/15, 5/21/15, 5/29/15, 6/10/15, and 6/18/15. There was no documentation of a signed consent for the laboratory in client record #3. Client # 4 was admitted into treatment on 4/2/15 and was still active at the time of inspection. Client identifying information was released to a laboratory on 4/10/15, 4/15/15, 4/23/15, 5/1/15, and 7/1/15. There was no documentation of a signed consent for the laboratory in client record #4. Client # 7 was admitted into treatment on 9/29/14 and was discharged on 3/10/15. A release of information form was signed on 9/29/14 to release urine drug screen results, discharge summary, and PCPC to the client's insurance provider. Client # 9 was admitted into treatment on 9/11/14 and was discharged on 5/1/15. A release of information form was signed on 9/9/14 for the client ' s probation officer, however it did not specify what information was to be released. Additionally, client identifying information was released to a laboratory on 1/29/15, 2/10/15, 9/12/14, 9/30/14, and 12/29/14 . There was no documentation of a signed consent for the laboratory in client record #9. These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The client charts audited have been rectified to reflect correct releases of information per state policy. To ensure that all of our current charts are also correct with adequate releases of information, the clinical supervisor and quality assurance auditor are rectifying any other problems detected by correcting all releases of information that are not appropriately completed through our weekly client chart auditing system and processes set in place to audit all client charts. We are confident that since inspection, all charts have already been reviewed and corrected.
In order to prevent this from reoccurring, the facility director will meet with the clinical supervisor and develop a one day two hour training that will revisit and refresh individuals with the appropriate information that must be included in all releases of information completed for all clients admitted into the program. The training will be performed no later than10/30/2015. The information the training will focus on will include the name of the client, the facility or person the information will be released from, the facility or person the information will be released to, the specific information that will be released, the purpose of the disclosure, and the method that will be utilized of releasing the information. More specifically, the training will cover the five areas permitted to be released which include the following:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
After the training the facility director will follow up with clinical supervisor through face-to-face counselor weekly and/or bi-weekly supervisions and review records at random with counselors to make sure that the releases are being completed accordingly. |