INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 11-13, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Roxbury 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) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility fire drill log, the facility failed to document the use of alternate exit routes during fire drills.
The findings include:
The facility fire drill logs were reviewed on February 11, 2013. The facility failed to document the use of alternate exits during fire drills on the fire drill log.
During a discussion with the building manager on February 12, 2013, it was discovered that the corporate office had changed the fire drill log from last year.
The findings were confirmed by the Director of Plant Operations.
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Plan of Correction
The Director of Plant Operations is responsible for modification of fire drill log to include the use of alternate exits. The modification of the form will be completed for review in the next Medical Executive Committee meeting on 3/27/13. Compliance with the fire drill log documentation will be monitored monthly by the Director of Plant Operations and will reported in the Environment of Care Committee meeting monthly until four months of 90% compliance has been maintained. |
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 the client records, the facility released information that exceeded what was permissible by 4Pa. Code 255.5(b) in two of nine records reviewed.
The findings included:
4 PA Code 255.5 (b) limits the amount of information that can be released to insurance companies, managed care plans and other third party payers to:
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or
alcohol abuse and the frequency of such relapse.
Nine records requiring documentation of release of information forms were reviewed February 12-13, 2013. The facility released information that exceeded what was permissible by 4Pa. Code 255.5(b) in two of nine records reviewed, specifically client records # 4 and 8.
Client record #4 contained a release of information to the courts signed on 8/29/12 which allowed for the release of the psychiatric discharge summary/CC plan/DX page, psychological evaluation, educational information, psychiatric evaluation, consultations, H&P, lab/radiology data, concurrent review of treatment and family communication, demographic information, and insurance information.
Client record #8 contained a release of information for the county adult probation office signed on 1/30/13 which allowed for the release of the psychiatric discharge summary/CC plan/DX page, psychological evaluation, educational information, psychiatric evaluation, consultations, H&P, lab/radiology data, concurrent review of treatment and family communication, demographic information, and insurance information.
The findings were confirmed by the Project Director.
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Plan of Correction
Staff will be re-educated on proper completion of consents and confidentiality on the Chemical Dependency Unit by March 15, 2013. The Clinical Supervisor will complete chart audit of 20 charts monthly to ensure compliance and proper completion of consents. The results will be discussed and monitored in Performance Improvement Meeting Monthly. The audit will continue for a period of four months. Target Date of Completion: June 30, 2013. The release of information for both patients will be voided due to improper completion of release. Due to patients being discharged from the facility, a new release was not able to be obtained. |
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 shall 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 obtain an informed and voluntary consent for releases of information which included the purpose for the release on each consent to release information form in two of nine client records.
The findings include:
Nine client records requiring documentation of a consent to release information which included the purpose of the consent were reviewed February 12-13, 2013. The facility failed to obtain an informed and voluntary consent for releases of information which included the purpose for the release on each consent to release information form in two of nine client records, specifically records # 4 and 8.
Client # 4 was admitted into treatment on 8/28/12 and discharged on 9/21/12. A consent to release information to the courts was signed on 8/29/12. The facility documented a purpose of "other" without defining what specifically was being released.
Client # 8 was admitted into treatment on 1/29/13 and was still an active client at the time of the inspection. A consent to release information to the adult probation office was signed on 1/30/13. The facility documented a purpose of "other" without defining what specifically was being released.
The findings were confirmed by the Project Director.
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Plan of Correction
Staff will be re-educated on proper completion of consents and confidentiality on the Chemical Dependency Unit by March 15, 2013. The Clinical Supervisor will complete chart audit of 20 charts monthly to ensure compliance and proper completion of consents. The results will be discussed and monitored in Performance Improvement Meeting Monthly. The audit will continue for a period of four months. Target Date of Completion: June 30, 2013. The release of information for both patients will be voided due to improper completion of release. Due to patients being discharged from the facility, a new release was not able to be obtained. |