INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 21, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Care & Addiction Recovery Services 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to keep hot water temperature to not exceed 120 degrees in the staff and client bathrooms. The staff and client bathroom water temperature was 143 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.24. Bathrooms: LICENSURE
The nonresidential facility shall: (3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
Observations:
Based on a physical plant inspection, the facility failed to keep hot water temperature to not exceed 120 degrees in the staff and client bathrooms. The staff and client bathroom water temperature was 143 degrees.
These findings were reviewed with facility staff during the licensing process.
Plan of Correction:
Community Care & Addiction Recovery Services (CCARS) has created following POC in response to a deficiency found during an on-site licensing renewal inspection conducted on 12/21/2021 ? 12/21/2021
The Project Director spoke with the facility leasing liaison on 12/21/2021 to review this deficiency regarding water temperature that was identified to be noncompliance. The property liaison immediately arranged for the maintenance company to adjust the water temperature and ensure that the water heater is set to heat not more than 120 degrees to be DDAP compliant.
CCARS Project Director will perform periodic checks of the water temperatures to ensure ongoing compliance. Facility maintenance has now adjusted the temperatures and CCARS is now in full compliance.
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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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 5 was admitted on November 2, 2020 and discharged on August 12, 2021. An informed and voluntary consent from the client for the disclosure of information dated March 22, 2021 to a medical assistance office allowed the release of intake information, treatment plan, medical concerns and treatment schedule.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
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.
Observations:
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed.
Client # 5 was admitted on November 2, 2020 and discharged on August 12, 2021. An informed and voluntary consent from the client for the disclosure of information dated March 22, 2021, to a medical assistance office allowed the release of intake information, treatment plan, medical concerns, and treatment schedule.
These findings were reviewed with facility staff during the licensing process.
Plan of Correction:
Community Care & Addiction Recovery Services (CCARS) has created following POC in response to a deficiency found during an on-site licensing renewal inspection conducted on 12/21/2021 ? 12/21/2021
The Project Director and the office manager discussed the issue on 12/21/2021 and reviewed this deficiency regarding informed and voluntary consent from the client for the disclosure of information to outside agencies. The program director and the office Manager have made changes to the existing templates for consent to release client information to reflect the 5 areas allowed per law. The project manager will retrain all clinical staff verbally and ensure they understand the importance of correct releases to protect client information in areas permitted by the law. All old releases have been removed and new releases are in place for use with our clients moving forward.
To ensure ongoing compliance, the Project Director and the office manager will randomly inspect client records to ensure releases are being used correctly by the staff.
The Facility will be in full compliance effective 12/21/2021
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on one of two applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 60 days by letter with all discharges and seven days by phone call to a referral.
Client # 5 was admitted on November 2, 2020 and discharged on August 12, 2021. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.93(a)(11) LICENSURE
Client records:
709.93. Client records. (a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following: (11) Follow-up information.
Observations:
Based on one of two applicable client records reviewed, the facility failed to provide documentation of follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to the client occur within 60 days by letter with all discharges and seven days by phone call to a referral.
Client # 5 was admitted on November 2, 2020 and discharged on August 12, 2021. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process
Plan of Correction:
Community Care & Addiction Recovery Services (CCARS) has created following POC in response to a deficiency found during an on-site licensing renewal inspection conducted on 12/21/2021 ? 12/21/2021
It is CCARS policy to do a follow up to all our discharged clients after 60 days of discharge in order to offer support for ongoing recovery. The Project Director reviewed this deficiency with the office manager as the administrative staff that performs this task. The office manager will verbally retrain the administrative staff regarding the procedure of mailing out the follow up letter to all discharged clients withing 60 days of discharge and subsequently and file a copy of the letter in the clients' record. In response to this deficiency, a follow up letter was mailed to client # 5 and a copy was placed in client's record.
For ongoing compliance, the Project Director and the office manager will randomly inspect discharged files.
Facility will be in full compliance effective 12/21/2021
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