INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4, 2008 - August 6, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Abstinent Living At The Turning 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 September 5, 2008.
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Plan of Correction
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709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on review of four client records during the licensing inspection on August 5-6, 2008, the facility failed to document the purpose of the disclosure of information in 4 out of 4 client records reviewed. Finding:In client record # 1 and client record # 4 the purpose fails to explain why information is being shared. The documentation the purpose of the release of information re-stated who was going to receive the information. In client records 2 and 3 the purpose of the release was missing from the consent to release information forms.
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Plan of Correction
The Facility failed to document the purpose of disclosure of information on Consent forms in client records.
The Facility immediatly trained staff on Consent for Release for Information forms so that the Consent will include in detail the purpose of disclosure.
This was done by Julie Ealy and will be an ongoing process. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Based on the review of four client records on August 5 -6, 2008, the facility failed to document methods for control and accountability of drugs in three of four client records.. Finding:On medication logs in three out of four client records reviewed, the medication was not documented in accordance with the facility policy or the division standard. Documentation was missing on the medication administration record in client record # 1 for the dates of July 23 and July 24, 2008, and June 29, 2008. Two medications appeared to be added to the clients medication, but no date was given for when these medications were added, or when the administration of that medication was supposes to begin for the client. In client record #2, medication documentation was missing on the medication administration record on June 10, 11 and 14, 2008. On client record #3, medication documentation was missing on the medication administration record on February 19 and 20, 2008.
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Plan of Correction
The Facility failed to document methods for control and accountability on Medication Record.
The Facility has trained staff on documentation on the clients Medications Administration Record. This is an ongoing process and will be overseen by Operations Manager.
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709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of four client records on August 5- 6, 2008 the facility failed to document complete personal histories in four out of four client records reviewed. Findings:Client records #2, 3, and 4 failed to document complete family histories. Client record # 3 failed to document a complete legal history. Client records # 1, 2 and 3 failed to document a complete employment history. Client records # 3 and 4 failed to document a complete educational history. Client record #1 failed to document a military history. Client records # 1, 3 and 4 failed to document a complete recreational history. Client records # 1, 2, and 3 failed to document a complete sexual history.
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Plan of Correction
The Facility failed to document complete personal histories in client records.
The facilities Therapy staff has been trained on complete personal histories for client records.
This is an ongoing process and will be overseen by Director and Office Manager who does the client filing. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on review of client records on August 5-6, 2008, the facility failed to document a complete physical examination in two out of four client records.Finding:Client record #1 did not include documentation of a physical examination, and the physical examination in client record #3 did not contain the vital signs and general appearance.
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Plan of Correction
The facility failed to document a complete physical examination in client records.
The Facilities Assessment team will review Physical Examination form that is sent from referral source and make sure it is complete before admission of client. |