INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2007 to July 24, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on August 17, 2007.
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Plan of Correction
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The facility failed to limit the hot water temperature to 120 degrees Farenheit in the main building. The water tested at 160 degrees Farenheit.
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Plan of Correction
Temperature was not monitored. Water temperature has been lowered to 115. Water temp will be monitored monthly by Maintenance Department. This practice will be monitored by Safety Director at monthly safety meetings. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The facility failed to meet compliance with State and Federal confidentiality regulations for their policies on non-consensual releases. The following bold print is the facility policy which is in noncompliance and the italicized print is the licensing specialists response:
- Reporting to government agencies for disease prevention or control. Regulations do not permit the facility to disclose this information without the consent of the client. If there is a physician who can make the diagnosis, then the mandatory reporting should be done by that physician in such a way that the client is not identified as a participant in drug and alcohol treatment services.
- Domestic violence - Reporting to proper authorities. The only exception for non-consensual disclosures for domestic issues would fall under 42 CFR Part 2, Subpart B, Subsection 2.12(c) for reporting child abuse or neglect to the proper authorities. This exception allows for the reporting of the incident only and does not allow for the release of any other information without the client's written consent. The policy must be specific to the exception allowed in the Federal regulations. In addition, the state regulation at 28 Pa. Code Subsection 709.28(e) must be addressed to demonstrate that the facility knows it must contact the client as soon as possible after the release, after fully documenting the disclosure in the client record, and inform the client of the release telling them what was released, why and to whom. Reporting of other domestic violence issues would have to be done with client consent or by court order.
- Legal investigations - criminal or civil proceedings. Such a release would be a direct violation of state law at 71 P. S. Subsection 1690.108(b) and the Federal regulations at 42 CFR Part 2, Subpart B, Subsection 2.13. The only nonconsensual reporting of legal issues, specifically crimes on premises, would fall under 42 CFR Part 2, Subpart B, Subsection 2.22 (a)(3).
- To avert a serious threat to health or safety - only pertinent information to provide relief of emergency shall be released. The wording of this policy needs to be consistent with that found at 42 CFR Part 2, Subpart E, Subsection 2.63 and would require the facility to obtain a court order prior to making the release. Any actions that would fall short of these requirements would be a violation of the regulations.
- Compliance with worker's compensation law. There are no regulations that support the nonconsensual release of information for this purpose. Information releases for workman's compensation must be done with the signed consent of the client.
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Plan of Correction
Polciy followed HIPPA rather BDAP regulations. Policy has been revised to reflect BDAP standards. Staff will be informed and educated of this change. Facility director will monitor for compliance. |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
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Observations
The facility failed to maintain inventories on all prescribed stock medications. The facility has maintained inventories on all controlled substances but had not been maintaining inventories on all other prescribed stock medications. A regular account/record of stored drugs should include the date, person performing the inventory, amount of drugs on hand, amount used, amount needed and/or amount ordered (if applicable), balance, comments, etc.
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Plan of Correction
Only narcotic meds were counted. Pharmacy that supplies medications will install electronic med system to count all stock meds. System will be monitored by Nursing Director to ensure compliance. |