INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Freedom Recovery Center, LLC 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
The facility failed to document the direct observation of a counselor assistant in one of one personnel record reviewed on September 14, 2017. Employee # 5 was hired as a counselor assistant on January 30, 2017. The employees' bachelor degree is a non qualifying degree. The employee is a high school level counselor assistant and required direct observation for the first 3 months of employment. There was no documentation provided of direct observation from January 30, 2017 to April 30, 2017. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
CLINICAL DIRECTOR AND COMPLIANCE OFFICER WILL ENSURE THAT THE SUPERVISION PERIOD OF ANY COUNSELOR ASSISTANT HIRED IN THE FUTURE WILL FOLLOW THE REGULATIONS AS OUTLINED IN 704.9(C).
CLINICAL DIRECTOR AND COMPLIANCE OFFICER WILL BE RESPONSIBLE FOR ENSURING THE CORRECTIVE ACTION WILL BE IMPLEMENTED. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to maintain a written fire drill record that included whether the fire alarm or smoke detector was operative for the records reviewed on September 14, 2017. Fire drills records were reviewed for the time period of September 2016 to August 2017. Whether the fire alarm or smoke detector was operative was not documented for any of the drills reviewed. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
COMPLIANCE OFFICER SUBMITTED A REQUEST FOR AN EXEMPTION TO 705.28(d) (4) THAT A FIRE ALARM OR SMOKE DETECTOR BE ACTIVATED DURING A FIRE DRILL. OUR REQUEST WAS ACCEPTED ON 9-15-2017 BY THE PA DEPARTMENT OF DRUG AND ALCOHOL PROGRAMS.
SINCE THE FIRE ALARM SYSTEM WILL NOT BE ACTIVATED DURING FIRE DRILLS, THE COMPLIANCE OFFICER WILL BE RESPONSIBLE FOR DOCUMENTATION THAT THE FIRE ALARM SYSTEM IS WORKING. DOCUMENTATION WILL BE AVAILABLE FOR REVIEW DURING LICENSING INSPECTIONS. THIS DOCUMENTATION WILL BE UPDATED ON AN ANNUAL BASIS.
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709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
The facility failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.The facility's administrative records were reviewed on September 14, 2017. The project's fiscal year runs from January to December. The facility did not document an independent financial audit for the 2016 fiscal year.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PROJECT DIRECTOR HAS REQUESTED AN EXEMPTION FROM THE PA DOH FOR THE REQUIREMENTS OF 28 PA. CODE 709.25(a) FOR THE FISCAL YEAR OF JANUARY 1 TO DECEMBER 31, 2017. OUR PROJECT'S ANNUAL GROSS REVENUE WILL NOT EXCEED $500,000. PROJECT DIRECTOR IS RESPONSIBLE TO MAKE SURE THIS REQUEST IS DENIED OR APPROVED.
PROJECT DIRECTOR ON AN ANNUAL BASIS WILL MONITOR THE GROSS REVENUE AND REQUEST EXEMPTION AS NEEDED.
PROJECT DIRECTOR WILL BE RESPONSIBLE TO ENSURE AN AUDIT IS COMPLETED ANNUALLY, IF AN EXCEPTION IS NOT GRANTED. IF THE EXCEPTION IS GRANTED THE PROJECT DIRECTOR WILL ENSURE THAT THE TAX INFORMATION IS AVAILABLE DURING INSPECTIONS. PROJECT DIRECTOR WILL MAINTAIN ON SITE FOR REVIEW BY THE DIVISION, OTHER FINANCIAL DOCUMENTS RELATING TO THE PROJECT'S OPERATION (PAYROLL RECORDS, STAFFING RECORDS, ANNUAL TAX RETURNS, ANNUAL BUDGET RECORDS, BANK STATEMENTS, ETC.) |
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
The facility failed to obtain informed and voluntary consent forms for the disclosure of information contained in the client record in three of seven client records reviewed on September 14, 2017.The facility failed to obtain an informed and voluntary consent to release information in client records # 1, 2 and 3. There was no release of information documented in client record # 1 for the funding agency. Client records # 2 and 3, the consent to release information stated that revocation must be in writing. 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
HUMAN RESOURCE MANAGER(HRM) HAS REVISED OUR CONSENT TO RELEASE CONFIDENTIAL INFORMATION TO COMPLY WITH 42 CFR PART 2, SUBPART C, SUBSECTION 2.31 (a) (8). HUMAN RESOURCE MANAGER HAS DESTROYED THE INCORRECT CONSENTS. HUMAN RESOURCE MANAGER HAS ENSURED THAT ALL REVISED CONSENTS HAVE BEEN SIGNED BY THE CURRENT CLIENTS AND FILED ACCORDINGLY IN THEIR CHARTS.
HRM WILL BE RESPONSIBLE FOR MAINTAINING THE REVISED CONSENT TO RELEASE CONFIDENTIAL INFORMATION AND WILL ENSURE THAT ALL NEW CLIENTS SIGN AND RECEIVE THE REVISED CONSENT UPON THE NEW ADMISSION PROCESS.
HRM HAS OBTAINED A SIGNED CONSENT TO RELEASE CONFIDENTIAL INFORMATION TO THE FUNDING AGENCY FROM CLIENT #1 AND HAS ADDED THE CONSENT TO CLIENT #1 CHART.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to notify the clients of their rights in seven of seven client records reviewed on September 14, 2017. There was no documentation in client records # 1, 2, 3, 4, 5, 6 and 7 provided that the facility notified the clients of the following rights: A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment. The project may not discriminate in the provision of services on the basis of creed, ethnicity, color, marital status or sexual orientation. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
COMPLIANCE OFFICER HAS REVISED THE CLIENT RIGHTS TO BE IN COMPLIANCE OF WITH 028 PA CODE 709.30 CLIENT RIGHTS.
COMPLIANCE OFFICER HAS POSTED THE REVISED CLIENT RIGHTS THROUGHOUT THE FACILITY.
COMPLIANCE OFFICER HAS ENSURED WITH THE HUMAN RESOURCE MANAGER THAT THE REVISED CLIENT RIGHTS HAVE BEEN DOCUMENTED IN THE CLIENT HANDBOOK. HRM WILL ENSURE THAT THE REVISED CLIENT RIGHTS BE REVIEWED WITH ALL NEW CLIENTS DURING THE INTAKE PROCESS. HRM HAS DISTRIBUTED THE REVISED CLIENT RIGHTS TO ALL CURRENT CLIENTS.
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