INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Perry Human Services, 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on an annual licensing renewal inspection conducted on February 26,2020, the project failed to document an annual written individual staff performance evaluation was reviewed and signed by the employee in one out of four personnel records reviewed.
Employee #1 was hired on April 17, 2017 and was current employee at the time of the inspection. The employees personnel record contained an annual written individual staff performance evaluation; however, the evaluation was not signed or dated.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Director evaluation form will now have a line for a signature and date attached to the bottom, which is currently not on the one that was used. This will be reviewed and signed off on by the board annually following the completion of the directors evaluation and documented in board minutes. |
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 the review of client records, the facility failed to document a client-informed and voluntary consent to release information form for the disclosure of information in one of seven client records reviewed.
Client #7 was admitted on February 14, 2019 and was discharged on January 6, 2020. There was documentation from July 3, 2019 that indicated that facility staff spoke with the client's spouse; however, there was no valid informed and voluntary consent form documented in the client's record permitting the disclosure.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Additional confidentiality training will be completed with all clinical staff members regarding consents, focusing on specific releases of information and what information can be released. This will be documented in treatment meeting notes completed by the executive director. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form that included the client's signature in one out of seven client records reviewed.
Client #7 was admitted on February 14, 2019 and was discharged on January 6, 2020. An informed and voluntary consent form was completed on February 5, 2019 for the funding source; however, there was no client signature as of the date of the inspection.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Additional confidentiality training will be completed with all clinical staff members regarding consents to treatment, client signatures, and focusing on specific releases of information and what information can be released. This will be documented in treatment meeting notes completed by the executive director. |