INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13 - 14, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mon Yough Community Services 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.
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Plan of Correction
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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that included the number of persons in the facility at the time of the drill and the exit route used during monthly fire drills.
The findings include:
Fire drill records were reviewed on August 14, 2013 for the time period of September 2012 through July 2013. The facility failed to document the number of persons in the facility at the time of the drill and the exit route used during the following monthly fire drills: February 26, March 25, April 30, May 17, June 27 and July 31, 2013. The facility failed to document the exit route used during the January 31, 2013 fire drill.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the August 27 - 28, 2012 licensing inspection.
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Plan of Correction
Effective 8/15/2013, an updated "MYCS Emergency Fire Drill Evaluation" form was designed and implemented. A revised Fire Drill policy and procedure was defined, and all staff in the facility received training on this policy and procedure.
Facility Director corrected the Fire Drill record by implementing a new evaluation form which includes the date, time, address, total time of drill, exit routes prepared and used, the number of persons in the facility, problems encountered, and whether the fire alarm/smoke detector was operative, in addition to other items requested by facility staff.
Facility director will ensure the deficiency will not reoccur by reassigning responsibility for monthly fire drills to the Clinical Supervisor, who will review the monthly drill documentation with the Facility Director as needed.
The monthly documentation of the "MYCS Emergency Fire Drill Evaluation" will be kept in a separate binder, available for onsite review. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill records for September 2012 through July 2013 were reviewed on August 14, 2013. The exit route used was not documented for the fire drills conducted on the following dates: January 31, February 26, March 25, April 20, May 17, June 27 and July 31, 2013. The facility failed to document the use of any alternate exits during these monthly fire drills.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
This is a repeat citation from the August 27 - 28, 2012 licensing inspection.
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Plan of Correction
Effective 8/15/2013, an updated "MYCS Emergency Fire Drill Evaluation" form was designed and implemented. A revised Fire Drill policy and procedure was defined, and all staff in the facility received training on this policy and procedure.
Facility Director corrected the Fire Drill record by implementing a new evaluation form which includes the date, time, address, total time of drill, exit routes prepared and used, the number of persons in the facility, problems encountered, and whether the fire alarm/smoke detector was operative, in addition to other items requested by facility staff.
Facility director will ensure the deficiency will not reoccur by reassigning responsibility for monthly fire drills to the Clinical Supervisor, who will review the monthly drill documentation with the Facility Director as needed.
The monthly documentation of the "MYCS Emergency Fire Drill Evaluation" will be kept in a separate binder, available for onsite review. |
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 administrative materials, the facility failed to obtain a written informed and voluntary consent from the client prior to releasing urine samples to an outside laboratory for drug testing in two of two client records.
The findings include:
Ten client records were reviewed on August 14, 2013. Urine samples were sent to an outside agency for drug testing in two client records. The facility did not have a qualified services organization agreement in place for the outside laboratory. The facility failed to obtain a written informed and voluntary consent from the client prior to releasing urine samples to an outside laboratory for drug testing in client records # 2 and 3.
Client # 2 was admitted into treatment on March 20, 2013. Urine samples were released to an outside laboratory for drug testing without a written informed and voluntary consent from the client or a qualified service organization agreement with the laboratory on the following dates: July 3 and July 11, 2013.
Client # 3 was admitted into treatment on December 21, 2012. Urine samples were released to an outside laboratory for drug testing without a written informed and voluntary consent from the client or a qualified service organization agreement with the laboratory on the following dates: January 23 and February 6, 2013.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Effective 8/27/2013, all staff in facility have been instructed by Facility Director to discontinue releasing urine or other samples to any outside laboratory for any purposes until a qualified services organization agreement is in place, unless a written informed and voluntary consent from the client is received prior.
Clinical supervisor will conduct monthly chart audits to ensure that all clients have completed consent to release information for these events until the QSOA is obtained.
Facility director is currently working with agency senior management to develop and obtain a qualified services organization agreement which will be available onsite for review. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a family medical history and a history of illness and symptoms in five of five client records.
The findings include:
Ten client records were reviewed for medical histories on August 14, 2013. Five client records were reviewed for medical histories. The facility failed to document a family medical history and a history of illness and symptoms in client records # 1, 2, 3, 5 and 7.
Client # 1 was admitted into treatment on April 3, 2013. A medical history was completed on April 4, 2013. There was no documentation of a family medical history and a history of illness and symptoms in client record # 1.
Client # 2 was admitted into treatment on March 20, 2013. A medical history was completed on April 1, 2013. There was no documentation of a family medical history and a history of illness and symptoms in client record # 2.
Client # 3 was admitted into treatment on December 21, 2012. A medical history was completed on December 21, 2012. There was no documentation of a family medical history and a history of illness and symptoms in client record # 3.
Client # 5 was admitted into treatment on February 14, 2013. A medical history was completed on February 25, 2013. There was no documentation of a family medical history and a history of illness and symptoms in client record # 5.
Client # 7 was admitted into treatment on November 8, 2012. A medical history was completed on November 8, 2012. There was no documentation of a family medical history and a history of illness and symptoms in client record # 7.
The facility director and counselor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Effective 8/30/2013, a format for collecting both client and family medical history and history of illness and symptoms will be designed and approved by facility supervisor and director for immediate implementation. All staff will receive training on completing this additional information to the assessment.
Clinical supervisor conduct monthly chart audits to ensure familiy medical history and history of illness and symptoms is included.
This addendum to the assessment will be completed on all current clients no later than 9/27/2013 if client is available.The assessment will continue to be located in the client record as is currently. |