INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 1, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lehigh Valley Hospital - Schuylkill - Counseling Center - North 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) (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 the facility's June 2021 through April 2022 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills. The facility utilized the main exit route during all reviewed fire drills conducted.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
1. Review requirement with Director of facilities management as that department is responsible for conducting monthly fire drills.
2. Review fire drill documentation quarterly to monitor compliance
Responsible person: Program Director
Compliance Date 6/30/22 with ongoing quarterly monitoring. |
711.43(d)(2) LICENSURE Informed/voluntary Consent
711.43. Client records.
(d) Confidentiality.
(2) 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, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven applicable client records reviewed.
Client #10 was admitted for intake, evaluation, and referral services only on October 28, 2021. There was documentation of disclosures to a transportation service on October 28, 2021; however, there was no valid consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Review Confidentiality Policy with Clinical Staff to insure a valid concent is in the record before any referral to outside services occurs.
Random Assessment chart review (5 charts monthly) to monitor for ongoing compliance.
Responsible Person: Program Director
Compliance by 6/30/22 with ongoing audit monthly |
711.43(d)(2)(iv) LICENSURE Client's signature
711.43. Client records.
(d) Confidentiality.
(2) 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:
(iv) The dated signature of client or guardian.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on release of information forms in one of seven applicable client records reviewed.
Client #10 was admitted for intake, evaluation, and referral services only on October 28, 2021. There were release of information forms to a treatment provider, two government agencies, two funding sources, an emergency contact, and a probation and parole agency that were all signed and dated by the witness on October 28, 2021; however, the dated signature of the client was not documented on any of the consent to release information forms.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Confidentiality Policy Review with Clinical Staff to insure understanding of all necessary elements of a valid consent. All releases will be signed and dated prior to any release of information.
2. Random Chart audit (3 per counselor/monthly) to insure compliance with releases.
Responsible Person: Program Director
Compliance by 6/30/22 with ongoing monthly audit. |
711.92(c)(2) LICENSURE Type & Frequency of TX
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in seven of seven applicable client records reviewed.
Client #1 was admitted on December 23, 2021 and was still active at the time of the inspection.
Client #2 was admitted on January 6, 2022 and was still active at the time of the inspection.
Client #3 was admitted on January 26, 2022 and was still active at the time of the inspection.
Client #4 was admitted on July 23, 2021 and was discharged on December 27, 2021.
Client #5 was admitted on August 2, 2021 and was discharged on November 4, 2021.
Client #6 was admitted on September 20, 2021 and was discharged on January 31, 2022.
Client #7 was admitted on October 7, 2021 and was discharged on January 18, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Review with clinical staff including type and frequency of services to the "methods" section of the treatment plan.
2. Ongoing review by clinical supervisor at the time of clinical document submission and approval with feedback in clinical supervision as appropriate
3. Monthly chart audit (3 charts/counselor) to monitor compliance.
Responsible person: program Director
Compliance by 6/30/22 with ongoing monthly monitoring |
711.93(c)(2) LICENSURE Consent to Release-Informed & Voluntary
711.93. Client records.
(c) Confidentiality.
(2) 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, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven applicable client records reviewed.
Client #5 was admitted to the outpatient level of care on August 2, 2021 and was discharged on November 4, 2021. There was documentation of a disclosure to a psychiatrist on September 23, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.Confidentiality Policy review with clinical staff to insure compliance with a signed release prior to the the release of patient information.
2. Random Chart Audit (3 charts/counselor monthly to insure compliance with consents
Responsible person; program Director
Compliance by: 6/30/22 with ongoing monthly audit. |