INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Salvation Army Harbor Light Center 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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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 exceeded the limitations imposed at 4 Pa. Code 255.5 when documenting the specific information to be disclosed on the consent to release information form in six of six records.
The consent to release information forms were documented during the intake process and indicated financial information would be released to the funding entity in the following client records:
Client # 1 was admitted February 15, 2022. In addition, a consent to a judge indicated financial information would be released.
Client # 2 was admitted December 3, 2021.
Client # 3 was admitted January 24, 2022.
Client # 4 was admitted July 30, 2021 and discharged November 29, 2021. In addition, a consent to a government agency indicated financial information would be released.
Client # 5 was admitted August 27, 2021 and discharged January 14, 2022.
Client # 6 was admitted July 29, 2021 and discharged September 14, 2021. In addition, a consent to a judge indicated financial information would be released.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the annual licensing inspection conducted on March 16, 2021.
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Plan of Correction
As of 5/10/2022 all ROI's have been updated to eliminate any and all information which falls outside of the "Five Points" such as financial information. All staff who complete consent forms have been given the new consent form template and the old ones with all of the information which fell outside of the scope have been destroyed. All staff have been trained on how to complete the consent forms appropriately, what they are to contain. The Clinical Supervisor, through weekly chart reviews, will inspect the consent forms to make sure they are accurate, the correct form, and contain all of the necessary release of information applicable to that person. Lastly, all existing clients will re-sign consent forms in the new format and have the old formatted consents destroyed. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on an inspection of the medication storage area and facility staff interviews, the facility failed to document quarterly inspections of the medication storage area from March 2021 through March 2022.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 5/10/2022 a Quarterly Medication Inspection form in accordance with DDAP and Pennsylvania State requirements has been created and contains all of the necessary information to do a quarterly inspection of the medication room, medication storage area, and listed appropriate documentation. This form also indicates proper disposal and storage methods for various medications, such as insulin or controlled substances. This form is kept in the MAR in the medication chart and is locked at all times. Staff in charge of medication, logging, and disposal will conduct quarterly inspections beginning 5/1/2022. All completed inspection forms will be given to the Executive Director for verification and filing/maintenance of the completed records. |