INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 5, 2018, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Hispanic American Organization 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of facility records conducted during the on-site inspection, the facility failed to conduct fire drills at least once every month.
The facility did not conduct fire drills for the following months :
*July of the year 2017
*August of the year 2017
*September of the year 2017
*October of the year 2017
*November of the year 2017
*December of the year 2017
*January of the year 2018
These findings were reviewed with facilty staff as part of the inspection process.
|
Plan of Correction
705.28 (d) Fire Safety to non residential facility.
HAO will conduct fire drills once monthly, on a random basis. False alarms within the building may be used to fulfill the requirements of a fire drill when all the phases of Rescue, Alarm, Contain and Evacuate are exercised and the false alarm is during regular business hours. A fire drill log will be maintained by the HAO Program Director or/and the Emergency Plan Manager and/or Emergency Plan Coordinator; which will indicate the date, time needed for completion, number of patients and visitors and staff involved; after securing everyone to the safe designated areas, comments of significant events, whether alarm was activate, whether alarm worked and corrective actions required if any.
HAO D&A Manualhas been revised (page 21/100). An unannounced fire drill was done on 2/22/2018. Drill was conducted by Emergency Plan Manager and Emergency Plan Coordinator. After securing everyone to the safe areas, there was a final count of twenty employees and eighteen (18) patients and visitors. Count done by Compliance Officer. The pilot training Seminar and drill log with signatures by employees is on file kept by Human Resources Dept.
Previously system was been installed and tested.
|
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
|
Observations
Based on a review of facility records conducted during the on-site inspection, and based on staff interviews conducted during the on-site inspection, the facility failed to comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The consent to release information template that the facility uses for probation, parole, law enforcement, government agencies and insurance companies authorizes the release of client psychosocial evaluations, psychiatric evaluations, laboratory results, medical records, school records and legal records. 12 of 12 client records reviewed used these consent to release information forms for government agencies and/or insurance companies.
4 Pa. Code 255.5(b) limits the information to be disclosed to certain individuals and institutions even with the written consent of the client. The following restrictions apply to 4 Pa. Code 255.5(b):
Restrictions. Information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following:
(1) Whether the client is or is not in treatment.
(2) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
L 0271 709.28 CONFIDENTIALITY
Relating to projects and coordinating bodies: Release of information to Parole Officers, Judges, Referral to other programs/agencies are done according to PA code 255.5.
A Form has been created for HAO D&A PROGRAM AS OF 3/9/2018 and is already included as part of documentation package on each patient's file. D&A Manual has been updated with this revised form.
|
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on a review of facility records conducted during the on-site inspection, and based on staff interviews conducted during the on-site inspection, the facility failed to document that it informed clients of their rights in 12 of 12 client records reviewed.
These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
L 0297 709.30
Based on Section 7 of act 71 P.S. (Points 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right sile by reason of treatment.
A staff meeting was done on Tuesday March 13 to discuss a form created for HAO D&A Program with six Clients rights:
1. A client receiving care or treatment under sectuon 7 of the ACT (71 P.S. PTS. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2. The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, orientation, handicap or religion.
3. Clients have the right ti ubspect their own records prior ti the inspection by the client if the director determines that the information maybe detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
4. Clients have the right to appeal a decission limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoanda to their own records.
Once the document is given to client, the counselor will provide a copy of the form to the client and will keep a copy on client's file in order to have the attestation that client was given a copy of the document. The counselor is responsible that the client receives his rights during the intake process.
Documents is signed by both Client and Counselor.
Form is already included as part of documentation package on each patient's file. |