INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection. The inspection will be divided into two parts. 1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.This report is a result of Part 2, an abbreviated on-site inspection, conducted on January 20, 2021 through January 21, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1. Based on the findings of Part 2, an abbreviated on-site inspection, Aldie Counseling Center 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
The facility failed to ensure that all heaters were permanently mounted or installed. Based on a physical plant inspection conducted at approximately 9:00am, a portable space heater was found in a counseling office. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The portable space heater has been removed from the property and the subject counselor has been informed of the violation. Subsequently the clinical director has informed all staff that space heaters are prohibited by State regulation. The CEO will further reinforce the requirement at the staff meeting scheduled for February 24, 2021. Thereafter, as part of monthly routine inspections the office manager will visit each office to ensure that there are no space heaters. The results will be charted in a log similar to the monthly fire-drill log. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to document the name of the specific person, agency, or organization to whom a disclosure would be made to on a consent to release information form in one of eleven client records reviewed.Patient #5 was admitted on April 27, 2020 and was discharged on January 8, 2021. There was a consent to release information form, signed and dated by the client on April 27, 2020, but the consent form did not include a specific name of the person, agency, or organization to whom the disclosure would be made to. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Director has reviewed the requirement with all clinical staff. The CEO will further reinforce the requirement at the full staff meeting scheduled for February 24, 2021. Thereafter consent forms will be reviewed by the clinical supervisors as part of regular clinical supervision. Therapists will be required to bring at least two client charts to each supervision for a review of clinical documentation. The forms will also be checked as part of regular chart audits. |