INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 28 - 29, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Abstinent Living at the Turning Point at Washington 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to document a sufficient number of staff persons were trained in first aid skills to ensure coverage during their hours of operation based on a review of the April and May 2019 staff schedules on May 28, 2019.
The facility's hours of operation are twenty-four hours per day, seven days per week.
There were no staff persons trained in first aid skills for the 12 AM - 8 AM shift on the following dates: April 13, April 19, April 20, April 23, April 26, April 27, April 30, May 3, May 4, May 7, May 10, May 11, May 14, May 17, May 18, May 21, May 24, May 25 and May 28, 2019.
The findings were reviewed with staff during the licensing process.
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Plan of Correction
The Operations Manager/Admissions Director confirms that one staff member had the required CPR training, but did not have the required First Aid training. That staff member received the required First Aid training prior to her next shift. In the future, the Operations Manager/Admissions Director and the Resident Assistant Supervisors will ensure that all new staff have both the CPR and First Aid certifications prior to working any shifts without other staff support. This will be overseen by the Project Director. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to ensure all exits from the residential facility were unobstructed based on a physical plant inspection conducted on May 29, 2019 at approximately 11:45 AM.
The facility's maintenance staff person was unable to open the window screen to access the fire escape ladder that was located outside of the second floor bedroom window.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager/Admissions Director confirms that during a recent renovation, the exterior of the building was painted, and the painters mistakenly painted said screen shut. The screen was immediately removed by our maintenance staff. In the future, maintenance staff will check all exits to ensure there are no obstructions during their weekly duties at the Turning Point. This will be overseen by the Project Director and the Operations Manager/Admissions Director. |
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
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 client records reviewed on May 28 - May 29, 2019.
Client # 6 was admitted August 14, 2018 and discharged February 6, 2019. The client's name, location and provider of their drug and alcohol treatment was faxed to a referral source on November 20, 2018.
The facility also failed to document a consent to release information form that was compliant with Federal confidentiality regulations by requiring the client to revoke their consent in writing in seven of seven client records reviewed on May 28 - 29, 2019.
A consent to release information to a medical provider was documented during the intake process and included the following statement: "This authorization may be withdrawn at any time in writing".
Client # 1 was admitted December 18, 2018.
Client # 2 was admitted March 15, 2019.
Client # 3 was admitted February 6, 2019.
Client # 4 was admitted October 4, 2018 and discharged January 30, 2019.
Client # 5 was admitted June 26, 2018 and discharged December 20, 2018.
Client # 6 was admitted August 14, 2018 and discharged February 6, 2019.
Client # 7 was admitted August 30, 2018 and discharged January 31, 2019.
In addition, the facility failed to comply with Federal confidentiality regulations by not permitting the client to revoke their consent to release information at any time in client records # 1, 2, 3 and 4.
These clients signed a form during the intake process that included the following statement: "I hereby acknowledge that I will not be permitted to withdraw my consent for any drug and alcohol program, county drug and alcohol court program and/or my probation officer".
This statement is in violation of Federal confidentiality regulations as the client can revoke their consent for any drug and alcohol program at any time and also revoke their consent for the courts and probation unless the client was court mandated into treatment. There was no documentation of court ordered treatment in client records # 1, 2, 3 and 4.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager/Admissions Director confirms that for Client #6, certain information was released without a proper consent in her chart.
The Operations Manger/Admissions Director confirms that the consent form being used did include the language "This authorization may be withdrawn at any time in writing". Immediately upon being notified that said language is non-compliant, the consent form was changed to reflect that "This authorization may be withdrawn at any time."
The Operations Manager/Admissions Director confirms that there was language on our consent forms prohibiting a client from revoking the consent for "any drug and alcohol program, county drug and alcohol court program and/or my probation officer". Immediately upon being notified that this language is non-compliant, unless a client is court ordered to treatment and a copy of the court order is in the chart, the consent form was changed to eliminate that language.
The Operations Manager/Admissions Director will ensure that all consent forms are updated, as noted above. Additionally, the Operations Manager/Admissions Director will ensure that all applicable staff is re-trained on the importance of confidentiality and the requirement for proper consents prior to releasing any information regarding said clients. This will be overseen by the Project Director and the Operations Manager/Admissions Director.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to document the name of the person, agency or organization to whom disclosure is made on the written, informed and voluntary consent from the client for the disclosure of information contained in the client record in five of seven client records reviewed on May 28 - 29, 2019.
Client # 2 was admitted March 15, 2019. The consents were dated March 15, 2019.
Client # 3 was admitted February 6, 2019. The consent was dated February 6, 2019.
Client # 5 was admitted June 26, 2018 and discharged December 20, 2018. The consents were dated June 26, 2018.
Client # 6 was admitted August 14, 2018 and discharged February 6, 2019. The consents were dated August 14 and August 30, 2018.
Client # 7 was admitted August 30, 2018 and discharged January 31, 2019. The consent was dated August 30, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager/Admissions Director confirms that the name of the person, agency or organization to whom disclosure is made was not documented properly on the consent form. The Operations Manager/Admissions Director will ensure that all applicable staff is re-trained as to the information required on the consent form, and the importance of clearly documenting all required information. The Operations Manager/Admissions Director will also review consent forms as they are filed in the client's chart to ensure that all applicable information is documented. This will be overseen by the Operations Manager/Admissions Director and the Project Director. |
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
The facility failed to document the purpose of disclosure on the written, informed and voluntary consent from the client for the disclosure of information contained in the client record in seven of seven client records reviewed on May 28 - 29, 2019.
Consents for the client's primary care physician were completed during the intake process and did not include the purpose of disclosure.
Client # 1 was admitted December 18, 2018.
Client # 2 was admitted March 15, 2019.
Client # 3 was admitted February 6, 2019.
Client # 4 was admitted October 4, 2018 and discharged January 30, 2019.
Client # 5 was admitted June 26, 2018 and discharged December 20, 2018.
Client # 6 was admitted August 14, 2018 and discharged February 6, 2019.
Client # 7 was admitted August 30, 2018 and discharged January 31, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager/Admissions Director confirms that the consents for the client's primary care physician did not include the purpose of disclosure. The Operations Manager/Admissions Director made immediate changes to the primary care physician consent to ensure that the purpose of disclosure is properly documented. The Operations Manager/Admissions Director will ensure that all applicable staff is re-trained as to the importance of clearly documenting the purpose of disclosure on all consents. This will be overseen by the Operations Manager/Admissions Director and the Project Director. |
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
The facility failed to document a copy of the consent was offered to the client in seven of seven client records reviewed on May 28 - 29, 2019.
Consents for the client's primary care physician were completed during the intake process. There was no documentation the clients were offered a copy of these consents.
Client # 1 was admitted December 18, 2018.
Client # 2 was admitted March 15, 2019.
Client # 3 was admitted February 6, 2019.
Client # 4 was admitted October 4, 2018 and discharged January 30, 2019.
Client # 5 was admitted June 26, 2018 and discharged December 20, 2018.
Client # 6 was admitted August 14, 2018 and discharged February 6, 2019.
Client # 7 was admitted August 30, 2018 and discharged January 31, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager/Admissions Director confirms that the consents for the client's primary care physician did not include documentation that the clients were offered a copy of these consents. The Operations Manager/Admissions Director made immediate changes to the primary care physician consent to ensure that they clearly document that the client is offered a copy of the consent, and whether or not they accept a copy. The Operations Manager/Admissions Director will ensure that all consents note that a client is offered a copy and whether or not they accept a copy. The Operations Manager/Admissions Director will ensure that all applicable staff is re-trained as to the importance of clearly documenting that a client is offered a copy, and whether or not they accept a copy of all consents. This will be overseen by the Project Director. |