INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 8, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill log and an interview with the Facility Director, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
On March 8, 2016, the facility's fire drill log was reviewed since the last inspection April 14, 2015 until February 2016. The facility failed to set off a fire alarm or smoke detector during each monthly fire drill.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 project failed to document informed and voluntary consent to release forms that complied with Pa Code 255.5.
The findings include:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed
Six client records were reviewed on March 8, 2016. The project failed to document informed and voluntary consent to release forms in all client records reviewed, # 1, 2, 3, 4, 5 and 6.
1. The project has a "Managed Care/Insurance Company Authorization to Release Information Form" that all clients sign and agree to consent to release. The "Managed Care/Insurance Company Authorization to Release Information Form" is a project wide template form. The other box is checked off on this template form with the pretext "level of care evaluations, Authorizations, Status reports and Recommendations, Chart contents."
The release or documentation of the release of the client's "level of care evaluations and chart contents" does not comply with the stipulations of 255.5.
2. In addition, the project has a form titled "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company - The Light Program/Life Counseling Services/Rehab After Work," that was revised 10/15.
The form documents, "My signature below indicates my permission for The Light Program/Life Counseling Services/Rehab After Work to bill my insurance for payment. I give my permission to disclose information such as my diagnosis, my medication and dates I will be attending, as well as other pertinent information in order for my insurance company to grant authorization of my attendance."
The release or documentation of the release of the client's "medication and dates I will be attending as well as other pertinent information in order for my insurance company to grant authorization of my attendance" does not comply and exceeds the limitations imposed at 255.5.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individualized treatment and rehabilitation plan in six of six records reviewed.
The findings include:
On March 8, 2016, six client records were reviewed to ensure the facility completed individualized treatment and rehabilitation plans with the client. The facility failed to ensure that treatment and rehabilitation plans were individualize and developed with the client, in client records, # 1, 2, 3, 4, 5 and 6.
Client # 1 was admitted to the facility on December 7, 2015. The facility documented a template treatment plan for client # 1 on December 7, 2015. Client # 1's treatment plan was not individualized and was nearly identical to treatment plans that were reviewed in other client records. The treatment plan template had pre-populated text and boxes that needed to be checked off. However, none of the boxes were checked off and the plan was not signed by client # 1.
Client # 2 was admitted on December 3, 2015. The facility documented a template treatment plan for client # 2 on December 3, 2015. Client # 2's treatment plan was not individualized and was nearly identical to treatment plans that were reviewed in other client records. The treatment plan template had pre-populated text and boxes that needed to be checked off. However, none of the boxes were checked off and the plan was not signed by client # 2.
Client # 3 was admitted on December 10, 2015. The facility documented a template treatment plan for client # 3 on December 10, 2015. Client # 3's treatment plan was not individualized and was nearly identical to treatment plan forms that were reviewed in other client records. The treatment plan template had pre-populated text and boxes that needed to be checked off. However, none of the boxes were checked off and the plan was not signed by client # 3.
Client # 4 was admitted on December 7, 2015. The facility documented a template treatment plan for client # 4 on December 7, 2015. Client # 4's treatment plan was not individualized and was nearly identical to treatment plan forms that were reviewed in other client records. The treatment plan template had pre-populated text and the plan was not signed by client # 4.
Client # 5 was admitted on January 11, 2016. The facility documented a template treatment plan for client # 5 on January 11, 2016. Client # 5's treatment plan was not individualized and was nearly identical to treatment plan forms that were reviewed in other client records. The treatment plan template had pre-populated text and boxes that needed to be checked off. However, none of the boxes were checked off and the plan was not signed by client # 5.
Client # 6 was admitted on January 15, 2016 and discharged on February 26, 2016. The facility failed to document an individual treatment plan for client # 6's duration of treatment.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |