INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 26, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Diakon Child, Family and Community Ministries 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel/training records, the facility failed to document that acceptable CPR training and certification was provided to a sufficient number of staff persons, so that at least one person trained in the skill is onsite during all hours of operation for the facility.
The findings include:
Twelve personnel/training records were reviewed on May 26, 2015. In twelve of twelve personnel records, the facility failed to document that the employee has completed acceptable CPR training and certification. The facility was unable to demonstrate that at least one staff person with acceptable CPR training and certification is onsite during all hours of the facility's operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Preparation and submission of this plan of correction is required by State and Federal law. This plan of correction does not constitue admission for purposes of general liability, professional malpractice or any other court proceeding.
The Clinical Director will ensure that staff members will participate in CPR/First Aid training. The training will be provided by a Diakon certified CPR/first aid trainor at the Mechanicsburg facility located at 960 Century Drive.
The members of staff trained will be sufficient enough to cover all working hours.
Documentation of completed trainings will be kept in the employee training file. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent which documented the name of the person, agency, or organization to whom the disclosure was made in one of ten client records reviewed. Additionally, the facility failed to obtain the dated signature of the client as provided for under 42 CFR 2.31 (relating to form of written consent) in one of ten records.
The findings include:
Ten client records which required documentation of an informed and voluntary consent were reviewed on May 26, 2015. The facility failed to obtain an informed and voluntary consent which documented the name of the person, agency, or organization to whom the disclosure was made in client record #6. Additionally, the facility failed to obtain the dated signature of the client as provided for under 42 CFR 2.31 (relating to form of written consent) in client record #1.
Client #1 was admitted into treatment on 6/12/14 and was still active at the time of the inspection. A consent to release information form for the client's relatives was signed by the client, but the client's signature was not dated. As the facility documented that the consent form expired one year from the date signed, the facility also failed to document the date, event, or condition upon which the consent would expire.
Client #6 was admitted into treatment on 8/19/14 and was still active at the time of the inspection. A consent to release information form signed by the client on 8/19/15 did not specify the name of the person, agency, or organization to whom the disclosure was made. The facility only documented that the disclosure was made to a "managed care organization".
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Records of Clients # 1 and 6 cannot be corrected retroactively.
The Clinical Director/designee will ensure new consents are completed and placed in the charts of clients #1 and #6.
The Clinical Director/designee will re-educate the staff on proper completion of consent forms.
The Clinical Director/designee will conduct monthly random chart audits to ensure compliance. Any identified issues will be addressed by the Executive Director as appropriate. |
715.13(b) LICENSURE Patient identification
(b) A narcotic treatment program shall maintain onsite a photograph of each patient which includes the patient 's name and birth date. The narcotic treatment program shall update the photograph every 3 years.
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Observations
Based on a review of patient records, the facility failed to maintain a photograph of each patient which includes the patient's name and birth date, in four of ten client records reviewed.
The findings include:
Ten client records were reviewed on May 26, 2015. Five of the ten clients receive prescriptions for Buprenorphine. These five client records require that the record include a photograph of the client, which includes the client's name and date of birth. Client records #1, 2, 7, and 8 did not include documentation of a photograph or identification which included the patient's name and date of birth.
Client #1 was admitted into treatment on 6/12/14 and was still active at the time of the inspection. There was no photograph or identification which included the patient's name and date of birth, in the client's record.
Client #2 was admitted into treatment on 9/17/10 and was still active at the time of the inspection. There was no photograph or identification which included the patient's name and date of birth, in the client's record.
Client #7 was admitted into treatment on 1/8/15 and was still active at the time of the inspection. There was no photograph or identification which included the client's name and date of birth, in the client's record.
Client #8 was admitted into treatment on 5/13/14 and was still active at the time of the inspection. There was no photograph or identification which included the client's name and date of birth, in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director/designee will ensure that photo identification is obtained from each patient prior to admission to the suboxone program. Initial photograph obtained will be the patient's drivers license or other form of identification which verifies the patient's date of birth.
The Clinical Director/designee will ensure that photographs will be updated every 3 years as required.
The Clinical Director/designee will conduct random chart audits will be conducted monthly to ensure compliance.
Any identified issues will be addressed by the Executive Director as appropriate. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every 60 days in four of ten client records reviewed.
The findings include:
Ten client records requiring the documentation of a treatment plan update were reviewed during the renewal inspection on May 26, 2015. The facility failed to document a treatment plan update at least every 60 days in client records # 1, 2, 3, and 6.
Client #1 was admitted into treatment on 6/12/14 and was still active at the time of the inspection. The client's comprehensive treatment plan was completed on 7/16/14. The client's treatment plan updates were completed on 9/24/14, 11/19/14, and 1/30/15.
Client #2 was admitted into treatment on 9/17/10 and was still active at the time of the inspection. The client's comprehensive treatment plan was completed on 11/1/10. The client's last five treatment plan updates were completed on 5/14/15, 2/24/15, 12/18/14, 10/23/14, and 7/31/14.
Client #3 was admitted into treatment on 10/1/14 and was discharged on 1/12/15. The client's comprehensive treatment plan was completed on 10/29/14. A treatment plan update was due to be completed by 12/29/14. The facility failed to document a treatment plan update in the client's record.
Client #6 was admitted into treatment on 8/19/14 and was still active at the time of the inspection. The client's last two treatment plan updates were completed on 3/4/15 and 1/8/15. A treatment plan update was due to be completed by 5/4/15. The facility failed to document a new treatment plan update in the client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical records of clients #1,2,3 and 6 cannot be corrected retroactively.
The Clinical Director/designee will re-educate staff on the proper completion of treatment plans, review and updates.
The Clinical Director/designee will conduct monthly random chart audits to ensure compliance.
Clients 1 and 6 are still active in treatment. Going forward all treatment plans will be completed every 60 days as required. |