INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24-26, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers-Net Steps. 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 and a plan of correction is due on April 18, 2008.
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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 upon a review of First Aid/CPR certifications and staffing schedules on March 24 & 25, 2008, the facility failed to ensure that a sufficient number of staff had first aid training and/or current CPR certification so that at least one person trained in these skills is onsite during the project's hours of operation.
The facility failed to ensure coverage for the residential program during the following hours on the following dates:
1. From 5:00 p.m. until 8:00 a.m. on 2/25/2008, 3/03/08, 3/10/08 & 3/17/08
2. From 12:00 a.m. until 8:00 a.m. on 2/26/08, 2/27/08, 2/28/08, 3/02/08, 3/04,/08, 3/05/08, 3/06/08, 3/11/08, 3/12/08, 3/13/08, 3/16/08, 3/18/08, 3/19/08, 3/20/08 & 3/23/08.
3. From 5:00 p.m. until 12:00 a.m. on 2/29/08, 3/07/08, 3/14/08 &3/21/08
4. From 4:00 p.m. until 12:00 a.m. on 3/01/08, 3/08/08, 3/15/08 & 3/22/08
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Plan of Correction
- As of March 26, 2008, a sufficient number of staff have been trained in both CPR and First Aid to ensure that there is at least one person trained in these skills on site during all hours of operation.
- The Program Director will monitor this process to ensure compliance with this regulation. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based upon a review of the facility fire drill records on March 18, 2008, the facility failed to document the use of alternate exits during fire drills.
The exit routes documented for fire drills consistently were listed as the main stairs for the residential program and the main entrance for the outpatient program.
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Plan of Correction
- As of April 1, 2008, three fire drills were conducted at the residential facility and three alternate exits routes were used.
- Facility Director will ensure that alternate exit routes are being used during fire drills and documented throughout the year in the fire drill report. |
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 upon a review of client records on March 24-26, 2008, the facility failed to ensure that consents to release information were informed and voluntary in twenty-one of twenty-one client records reviewed.
Client records #1R through 3R contained consents to release information that did not allow for the verbal revocation of consents. The consent to release information forms stipulated that if the client wished to revoke the consent that they had to do so in writing.
Client records #1R & 2R contained consent to release information forms for an emergency contact but failed to identify who the emergency contact was.
Client record #3R contained a consent to release information that allowed for the urine drug screen results to be released to the probation office.
Client records #1DF through 8DF contained consents to release information that did not allow for the verbal revocation of consents. The consent to release information forms stipulated that if the client wished to revoke the consent that they had to do so in writing.
Client records #1DF contained a consent to release information that allowed for the urine drug screen results to be released to the probation office and to the Philadelphia Health Management Corporation FIR/Treatment Court Program.
Client records #3DF, 4DF, 6DF, 7DF & 8DF contained consents to release information that allowed for the urine drug screen results to be released to the Philadelphia Health Management Corporation FIR/Treatment Court Program.
Client records #1M through 8M contained consents to release information that did not allow for the verbal revocation of consents. The consent to release information forms stipulated that if the client wished to revoke the consent that they had to do so in writing.
Client records #1M, 3M, 4M & 7M contained consents to release information for Probation and Parole that stipulated that the consent could not be revoked, but there was no corresponding documentation to demonstrate that treatment was a condition of the probation or parole..
Client records #1M, 3M, 4M & 7M contained consents to release information that allowed for the urine drug screen results to be released to the probation office.
Client records #2M, 3M & 6M contained consents to release information for the 1st Judicial District of Philadelphia that stipulated that the consent could not be revoked, but there was no corresponding documentation to demonstrate that treatment was a condition of probation or parole.
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Plan of Correction
- All consent forms will be updated and distributed to staff by 4.15.08.
- Staff will be trained by Clinical Supervisor regarding verbal revocation of a consent form by 4.15.08 by Clinical Supervisor.
- Clinical Supervisor will continue to monitor on a weekly basis the completeness of consents.
- Staff will be supervised on an on-going basis regarding the importance of confidentiality and the accurate completion of consent forms to ensure that NET is in compliance with this regulation.
- By 4.14.08, the assigned counselor will attempt to obtain emergency contact information to complete the consent forms in charts #1R and #2R.
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