INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15-17, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, UHS Recovery Foundation, Inc. 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 April 19, 2011.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on an interview with the Human Resource Director, the facility failed to ensure that CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
The findings include:
The Staffing Requirements Facility Summary Report form completed by the facility on March 14, 2011 was presented to the Licensing Specialist.
Page 7 of the Staffing Requirements Facility Summary Report included two drivers.
The surveyor inquired if the van drivers transported UHS clients and if they were CPR and first aid certified.
The Human Resource Director confirmed that the van drivers transport UHS clients.
The Human Resource Director also confirmed that the van drivers were not certified in CPR or first aid training.
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Plan of Correction
Human Resource Director will insure that the two identified drivers will attend CPR/ First Aide on Tuesday May 3, 2011. The CPR/ First Aide certificates will be placed in the drivers' personnel files. |
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, and an interview with the facility director and admissions officer, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in six of six client records.
The findings include:
Six client records were reviewed on March 16-17, 2011 for documentation of an informed and voluntary consent.
The facility did not obtain an informed and voluntary consent for the disclosure of client information in client records 1, 2, 3, 4, 5, and 9.
The facility failed to obtain an informed an voluntary consent for the disclosure of client information to the funding entity in client records # 1, 3, 4, 5, and 9.
An interview was conducted with the admissions officer at which time she confirmed that a consent was not obtained from the client before inputting the clients information in the government database. She stated that the facility is not releasing client information.
The facility failed to obtain an informed an voluntary consent for the disclosure of client information to a government agency in client records # 1, 2, 3, and 4.
An interview was conducted with the facility director/project director at which time they confirmed that a consent was not obtained from the clients' before submitting via fax transmittal medical applications and medical forms.
The facility director/project director stated that a consent was not needed as they are sending the documents at the clients request.
In addition, information was submitted to a government agency for client # 2.
The information that was released exceeded the limits imposed by 4 Pa. Code 255.5 (b).
The form requested the clients drug/alcohol use.
The facility completed this portion of the form, thus exceeding 4 Pa. Code 255.5.
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Plan of Correction
Releases for any and all government agencies have been added to the initial releases signed by clients upon admission. . The new releases were implemented as of March 25, 2011. The Admissions Director met with the Admissions staff on March 21, 2011 to orient them to the new procedure. Ongoing compliance will be monitored in Monthly Open Chart Audits conducted by Admissions Director.
Both Admission and Clinical Staff will be trained on the limits imposed by 4 Pa. Code 255.5 (b), namely 1) Whether the client is or is not in treatment; 2) The prognosis of the client; 3) The nature of the project; 4) A brief description of the progress of the client; and 5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse. Staff will be trained during the week of April 25, 2011 by Clinical Director and Clinical Coordinator. Compliance will be monitored in Monthly Open Chart Audits conducted by Admissions Director and Clinical Director. |