INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addiction Treatment 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
The facility failed to ensure that fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The fire extinguishers located in the building were last inspected by a local fire department or fire extinguisher company in 2015.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
The physical plant manager will purchase an additional fire extinguisher to be kept in the office at this location. The physical plant manager in collaboration with the clinical supervisor will be responsible for ensuring that this fire extinguisher is inspected annually by the Fire Extinguisher Company or local fire department. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
These changes will be implemented by May 1st, 2017. The clinical supervisor will oversee compliance with these changes
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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 document written acknowledgement that the clients were notified that: No client may be deprived of a civil rights solely by reason of treatment; Reasons for removing sections of the client's record shall be documented in the record and that the client has the right to appeal a decision limiting access to their records to the director, in six of six client records reviewed on March 28, 2017.
Six records were reviewed. Client records # 1, 2, 3, 4, 5, and 6 did not document that the client was informed of the above rights.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Changes were made to the Patient Rights section of the agency handbook to reflect this deficiency. A statement will be added stating: No client may be deprived of civil rights solely by reason of treatment. The following statements will be added to the section addressing clients' access to their records: Reasons for removing sections of your record will be documented in your record, and you have the right to appeal a decision limiting your access to your record to the program director.
Patient rights will continue to be reviewed at the intake appointment. An additional section will be added to the acknowledgement page of the intake document requiring the client's initials that the client rights have been reviewed.
These changes will be implemented by the clinical supervisor and reviewed with staff by the clinical supervisor to be completed by April 24th, 2017. The clinical supervisor will provide ongoing chart monitors to ensure that these changes are occurring.
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709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
The facility failed to document support services on six of six client records reviewed on March 28, 2017.
Six client records were reviewed. Client records # 1, 2, 3, 4, 5 and 6 did not document proposed support services on the comprehensive treatment plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will revise the current comprehensive treatment plan to include a section to prompt clinicians to identify support services in achieving the stated goals. The clinical supervisor will conduct training to educate clinicians on linking patients to support services such as MH therapy, psychiatry, PCP, AA or NA, SMART Recovery, Peer-based services, faith-based activities through a Church, etc.
These changes will be implemented by the clinical supervisor by May 1st, 2017. The clinical supervisor will conduct ongoing chart monitors to ensure compliance.
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