INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 13, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addictions Treatment 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 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records, the facility failed to document that staff were instructed in the use of the fire extinguisher upon staff employment in one of one record reviewed on April 13, 2021.
Employee # 1 was hired on June 17, 2019. Fire extinguisher training was not documented until July 1, 2019.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director shall ensure upon 1st full day of employment new hire shall be acclimated to building via tour and verbal processing/discussion of agency disaster. Formal training will occur on first day regarding use of fire extinguisher and new hire will be oriented to principles of Rescue, Alarm, Confine, Extinguisher/Evacuate (RACE) and Pull, Aim, Squeeze, Sweep (PASS). Sign off will be tracked through use of "Fire Safety and Disaster Plan Acknowledgement" form to be kept in
employee personnel file. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to document that all personnel on all shifts were trained to perform assigned tasks during emergencies in one of one record reviewed on April 13, 2021.
Employee # 1 was hired on June 17, 2019.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director shall ensure upon 1st full day of employment new hire shall be acclimated to building via tour and verbal processing/discussion of disaster plan and fire safety/preparation. Sign off will be tracked through use of "fire Safety and Disaster Plan Acknowledgement" form to be kept in
employee personnel file. |
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.
|
Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in five of seven records reviewed on April 13, 2021.
The client's name and diagnosis was released to the insurance company, during the intake process, to authorize drug and alcohol treatment services in the following client records.
Client # 2 was admitted December 28, 2020. In addition, the facility faxed a drug screen order to a hospital without written client consent or a Qualified Service Organization Agreement (QSOA) on December 30, 2020.
Client # 3 was admitted January 4, 2021.
Client # 4 was admitted September 23, 2020 and discharged March 24, 2021.
Client # 5 was admitted October 23, 2020 and discharged February 25, 2020.
Client # 6 was admitted November 17, 2020 and discharged March 17, 2021. In addition, a drug and alcohol treatment progress update was faxed to probation without written client consent on March 17, 2021.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Agency shall review all currently active charts and obtain written consent for these charts. Checks shall be tracked on newly updated Consent Summary Spreadsheet. Facility Director shall ensure all future first patient appointments by clinician occur on grounds. Prior to meeting with clinician, perspective patient will engage in registration process with support staff as written consent/releases of information are facilitated in this process. In the event patient is not comfortable with face to face interaction with clinician patient appointment will be facilitated with clinician in his/her assigned space and perspective patient utilizing Zoom via private computer room at the end of the hallway. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on a review of client records, the facility did document a consent to release information form but failed to include the dated signature of the client in four of seven records reviewed on April 13, 2021.
Consents for the following records were documented during the intake process.
Client # 2 was admitted December 28, 2020. Consents for a treatment provider, probation, physician and insurance company did not include the dated signature of the client.
Client # 3 was admitted January 4, 2021. Consents for a treatment provider, physician and insurance company did not include the dated signature of the client.
Client # 4 was admitted September 23, 2020 and discharged March 24, 2021. Consents for a treatment provider and insurance company did not include the dated signature of the client.
Client # 6 was admitted November 17, 2020 and discharged March 17, 2021. A consent for probation did not include the dated signature of the client.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Agency shall review all currently active patient charts and obtain written consent for these active charts. Agency shall utilize process of visual inspection of consents at time of facilitation to ensure consents are both signed and dated. In the event a paper release of information needs to be uploaded to the electronic medical record this documentation will be visually inspected and will not be uploaded until the client manually signs and manually dates paper(non-electronic) release of information. |
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.
|
Observations
Based on an inspection of the medication storage area and an interview with the project/facility director and nurse on April 13, 2021, the facility failed to document any quarterly inspections of the storage area from April 2019 through April 13, 2021.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director along with medical professional shall inspect the medication administration area at least quarterly and document. Areas of emphasis shall include ensuring any outdated drugs are removed from area, ensuring therapeutics are properly stored, ensuring separation of any oral and injectables, and having copies of current drug related regulations for therapeutics. |