INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2022 through July 27, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD-New Start II 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 the July 2021 through June 2022 fire drill logs, the facility failed to identify, on their fire drill log, the number of people in the facility at the time of the drill during every fire drill conducted during the reviewed period.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of New Start II will update Fire Drill log to include the number of people in the facility at the time of the drill.
The Director will inform and discuss changes to fire drill log during next staff meeting scheduled in August 16, 2022.
The Director will review and sign off on all fire drill logs monthly to ensure accuracy. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual and a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client record reviewed.
Per the policy and procedure manual, the program will contact the participant's emergency contact when the participant leaves treatment against facility advice.
Client #8 was admitted on June 14, 2022 and was discharged against facility advice on June 19, 2022. There was no attempted emergency contact notification documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will modify New Start II's discharge packet to include document identifying when and what emergency contact was called at time of participants decision to leave treatment against facility advice.
The Director will develop and add emergency contacts contact documentation to New Start II's discharge packet by August 6, 2022.
On August 16, 2022, The Director will meet with clinical staff who are responsible for contacting emergency contacts upon a participants decision to AFA to introduce, discuss and train on usage of required documentation. |
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, the facility failed to obtain an informed and voluntary consent to release information form prior to the disclosure of information in two of nine client records reviewed.
Client #2 was admitted on January 24, 2022 and was active at the time of inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #6 was admitted on November 1, 2021 and was discharged on July 7, 2022. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On August 16, 2022, Director will train staff on all sections of consent to release information. Discuss importance of completing intake packet at time of admission as it containing funders consent required for .
Director will follow-up to ensure that all clients intake consents are reviewed and sign at time of admission prior to funder being notified of clients admission.
Director will review charts monthly to ensure that all consents where completed accurately.
Director will meet with client 2, to ensure that consents have been signed for all outside contacted entities.
Client 6 is no longer a client of program.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of nine client records reviewed.
Client #1 was admitted on March 7, 2022 and was still active at the time of the inspection. The release of information form to an emergency contact was signed and dated by the client and witness on March 7, 2022, but the release form did not include the specific information to be disclosed.
This is a repeat citation from the July 22, 2021 to July 23, 2021 annual licensing renewal inspection.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On August 16, 2022, Director will train staff on all sections of consent to release information. Director will review section identifying reasoning for disclosure of information.
All consents signed will be reviewed by Director in real time to ensure consents are completed in it entirety and correctly.
Director will review charts monthly to ensure that all consents where completed accurately.
Director will meet with client 1, who is active client to review emergency contact consent and identify the reason for disclosure of the consent.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of the disclosure on consent to release information forms in one of nine client records reviewed.
Client #1 was admitted on March 7, 2022 and was still active at the time of the inspection. The release of information form to an emergency contact was signed by the client and witness on March 7, 2022, but the release form did not include the purpose of the disclosure.
This is a repeat citation from the July 22, 2021 to July 23, 2021 annual licensing inspection.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On August 16, 2022, Director will meet with and train staff on all sections of consent to release information. Director will review section identifying the information to be disclosed on the consent.
All consents signed will be reviewed by Director in real time to ensure consents are completed in it entirety and correctly.
Director will review charts monthly to ensure that all consents where completed accurately.
Director will meet with client 1, who is active client to review emergency contact consent and identify the purpose of the disclosure.
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709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the client on informed and voluntary consent to release information forms in one of nine client records reviewed.
Client #3 was admitted on March 3, 2022 and was still active at the time of the inspection. There was a release of information form to another treatment facility signed by the witness on March 3, 2022; however, the signature of the client was not documented on the release form.
This is a repeat citation from the July 22, 2021 to July 23, 2021 annual licensing renewal inspection.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On August 16, 2022, Director will train staff on all sections of consent to release information. Director will review importance and requirement for staff to obtain signature of client and date signed prior to the release of ant information.
All consents signed will be reviewed by Director in real time to ensure consents are completed in it entirety and correctly.
Director will review charts monthly to ensure that all consents where completed accurately.
Director will meet with client 3, who is active client to obtain signature and date on consent. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent was offered to the client in one of nine client records reviewed.
Client #1 was admitted on March 7, 2022 and was still active at the time of the inspection. There was a release of information form to another treatment provider signed by the client and witness on March 7, 2022; however, there was no documentation in the record indicating that a copy of the release form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On August 16, 2022, Director will train staff on all sections of consent to release information. Director will review process of offering of consent to clients at time consent are signed and review with client.
All consents signed will be reviewed by Director in real time to ensure that copy was offered to consumer.
Director will review charts monthly to ensure that all consents where completed accurately and in their entirety.
Director will meet with client 1, who is active client to offer copy of all consents and ensure that it is displayed on consent whether copy was accepted of rejected. |