INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 22, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Rehab Management 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:
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Plan of Correction
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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's January 2022 through January 2023 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts. The facility's hours of operation are Monday through Friday 9:00AM - 9:00PM. There were no fire drills conducted during the evening hours of operation as all drills conducted, during the reviewed period, were completed between the hours of 10:30AM through 1:30PM. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to abide by DDAP regulation, safety officers and clinical supervisors with the support of clinical director, quality manager, and director of compliance will conduct fire drills at different times of the day to reflect different staffing shifts during facility hours of operation. Identified staff listed will re-train on -site staff within 30 days with full compliance expectation as of 5/28/2023. Quarterly audits will occur by quality manager and clinical director in order to ensure consistency in accordance with the regulation. |
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
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in two of seven client records reviewed.Client #1 was admitted on May 12, 2022 and was active at the time of inspection. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.Client #7 was admitted on September 26, 2022 and was discharged on November 17, 2022. There was documentation of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Supervisor met with clinician after exit interview to review active client needing updated ROI on 2/28/23 with expectation of completion by next date of service on 3/7/2023. Action completed. Moving forward, the supervisor will conduct random chart audits of each clinician at a rate of two charts per clinician monthly to randomly inspect that proper consent is obtained that include the correct names of the identified entity per the respective release. An onsite group supervision has been conducted with all staff to to reinforce the consent requirements. Potential revisions of release of information in our electronic medical record are being explored by leadership in order to increase compliance. |
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
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on a release of information form in one of seven client records reviewed.Client #4 was admitted on September 28, 2022 and was discharged on November 17, 2022. A release of information form to an insurance company was signed and dated by the client on September 28, 2022; however, the name, agency, or organization was not documented on the form. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Supervisor will conduct random chart audits of each clinician at a rate of two charts/clinician monthly to randomly inspect that proper consent is obtained that include the correct names of the identified entity per the respective release. An onsite group supervision has been conducted with all staff to to reinforce the consent requirements. Potential revisions of release of information in our electronic medical record are being explored by leadership in order to increase compliance. |