INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 13 - 14, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alcohol and Drug Abuse 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill record log, the facility failed to document one monthly fire drill. The findings include: The fire drill record log was reviewed on January 8, 2015. The log was reviewed from December 2013 to December 2014. A fire drill was not documented for the month of May 2014. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff received a memo regarding the procedure and documentation of agency fire drills from the Executive Director on January 16, 2015. Program Supervisors of each department were instructed to provide follow up instruction and training to all staff in the January or February department staffing meetings.
Clerical staff in each office are responsible for initiating and documenting monthly fire drills except in Emporium where the assigned treatment staff are responsible. At Maple Manor the supervisor will assign a staff to conduct the monthly fire drill depending on the time of day or night when the drill will take place.
Fire drills must be completed between the first day and the tenth day of each month. All staff and clients who are in the office at time of monthly fire drill are required to participate.
Fire drills may not be announced ahead of time. However, the staff person in charge will notify ALL staff and clients in the office that a practice fire drill is going to take place just prior to sounding the fire alarm or smoke detector.
The smoke detector alarm and fire alarm must be set off at each check and documented on the fire drill sheet. The Bradford office and Maple Manor are exempt from sounding alarms during practice fire drills due to having an approved exception from the state as a result of having a shared alarm system involving other tenants in the building. These two offices are still required to have their alarms checked and documented twice per year. These checks must be completed between the first and tenth of July and December each year. The designated person in Bradford and at Maple Manor will clear this with the landlord.
Fire drill sheets must be either scanned and emailed or faxed to the administrative office to the attention of the clerical supervisor by the 20th of each month. The Executive Director and the Clerical supervisor will review the fire drill sheets to ensure that drills are occurring at each location each month and that they are being documented appropriately. The Clerical Supervisor will utilize a spreadsheet to track the monthly fire drills at each facility location.
Alcohol and Drug Abuse Services, Inc. Bradford Office is in full compliance as of February 3, 2015. |
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, the facility failed to document an informed and voluntary consent from the client for disclosure of information that indicated the specific information to be disclosed in one of ten client records.The findings included:Ten client records were reviewed on January 13 - 14, 2015. Ten client records required an informed and voluntary consent from the client; including the specific information to be disclosed. The facility failed to obtain an informed and voluntary consent from the client; including the specific information to be disclosed in client records # 10.Client #10 was admitted to treatment on 6-9-2014 and was discharged on 11-12-2014. A release of information to another provider was signed by the client on 5-27-2014. The release of information failed to include the specific information to be disclosed. A reporting form documented the disclosure of the information on 8-14-2014 and 10-21-2014.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff received a memo from the Confidentiality Compliance Officer/Outpatient Supervisor on 1-28-15 regarding the process of completing consent forms. Staff were informed that they must check the items being released on the consent form before any information is released. Supervisors of each department were instructed to provide follow up instruction and training to all staff in the January or February department staffing meetings. Program Supervisors of each department are responsible for monitoring compliance through file reviews.
The Outpatient Supervisor conducted follow up training and provided specific instruction to the Drug and Alcohol Treatment Counselor who failed to mark the information being released on the form in client #10's file on February 3, 2015. Clerical staff in each office have been instructed to review forms to ensure they are completed prior to filing them in the client file. If any form is found to be incomplete, clerical staff are instructed to notify the Outpatient Supervisor. The Confidentiality Compliance Officer/Outpatient Supervisor will provide an annual in house confidentiality training to all staff in September. The Outpatient Supervisor will also facilitate random selected peer file reviews every other month as part of the departmental staffing meeting. In addition, the Outpatient Supervisor will review discharge files monthly for compliance.
Alcohol and Drug Abuse Services, Inc. is in full compliance with this standard as of February 2, 2015. |