INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, George Junior Republic 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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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.
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Observations
Based on a review of client records and an interview with the facility director, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in two of seven records.
The facility billed for treatment services without written consent from the client in the following records:
Client # 5 was admitted September 23, 2021 and discharged February 4, 2022.
Client # 7 was admitted June 10, 2021 and discharged August 30, 2021.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
Facility Director will provide training with all Drug and Alcohol staff in regards to the inclusion of the 5-point consent to release information form for the funding entity prior to the release of client information.
Project Director will conduct quarterly file audits to ensure that the 5-point consents are accurate and in compliance with the documentation for all written consent.
The facility will be in compliance as of Monday, February 21, 2022. |
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
Based on a review of client records, the facility failed to document a written consent to release information form that included the name of the person, agency or organization to whom disclosure is made in one of seven client records.
Client # 1 was admitted November 30, 2021. The consent was dated December 1, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will provide training to all Drug and Alcohol staff to ensure that all release of information consents contain the name of the person and agency or organization to whom disclosure is made.
The Clinical Supervisor will review all open files and make any necessary corrections to the consent documents. The facility will be in compliance with this standard on Friday, February 25, 2022.
The Project Director will conduct quarterly file audits to ensure that consents to release information are in compliance with the documentation for all written consent. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of medication storage area inspections between January 2020 and December 2021 and facility staff interviews, the facility failed to document quarterly inspections of the medication storage area.
Inspections of the medication storage area were only documented for the following dates: March 10, 2020, June 10, 2020, September 30, 2020, January 21, 2021, March 16, 2021 and July 7, 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. The Director of Health Services and the Director of Business and Clinical Development have created an inspection form outlining areas listed in the citation that will be used by agency medical staff for inspection of the medication storage area.
2. Quarterly inspections will take place starting the week of February 28, 2022.
3. Agency policy and procedure has been created to encompass the scope of this inspection process. |