INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 16, 2018 through January 18, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Penn Foundation, 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:
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Plan of Correction
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection completed on January 18, 2018 at approximately 12:00 P.M., a group session was overheard by the Licensing Specialist in the hallway located outside group rooms 134, 137, 138, and 140.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.4(3) Counseling Areas
All counseling offices will be equipped with a white noise machine to ensure privacy of persons served. Machines were ordered on 2/2/2018 and will be placed in offices once the order in received. The program director will monitor use of the machines during counseling sessions.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection completed on January 18, 2018 at approximately 12:00 P.M., the facility failed to ensure that all heaters in the facility were permanently mounted or installed as a space heater was discovered in the medical office room 300, located on the first floor.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
705.8 Heating and Cooling
Effective immediately the space heater was removed from the Medical office room 300. By 2/15/18 all staff will be informed that space heaters are not permitted unless permanently mounted or installed and approved by the Penn Foundation maintenance department.
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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 total review of 23 client records, the facility failed to obtain a dated client signature on consent forms in 2 client records reviewed. Additionally, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 1 client record reviewed.
Outpatient client #1 was admitted on 12/14/17 and was still active at the time of inspection. There was a consent to release form, dated 12/14/17 to the client's parent. However, the consent form was missing the dated signature of the client.
Partial Hospitalization client #3 was admitted on 9/8/17and was discharged 10/3/17. A consent to release form was signed and dated on 9/8/17 to the insurance provider. However, the consent form allowed for the release of the client ' s biopsychosocial and summary of treatment to date.
Detox client #5 was admitted on 1/15/18 and was still active at the time of inspection. There was a consent to release form, dated 1/15/18, to a pharmacy. However, the consent form was missing the dated signature of the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.28 (c)(2) Confidentiality
All assessment and clinical staff will be re-trained by their direct supervisor in completion of releases of confidential information to ensure releases are fill out correctly and completely according to regulatory standards and signed by the person served. Training will be completed by 2/15/2018. Compliance will be monitored through quarterly chart audits conducted by the Program Director and Compliance Officer.
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709.81(b)(7) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of 5 partial hospitalization client records, there were missing preliminary treatment plans in 2 client records.
Partial hospitalization client #2 was admitted on 12/22/17 and was discharged on 1/12/18.
Partial hospitalization client #4 was admitted on 12/11/17 and was active at the time of inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.81 Intake and Admission
By March 1, 2018 the Recovery Center Outpatient staff will receive training in completing preliminary treatment plans for clients who are stepping down from higher levels of care. Training will be conducted during one of the group supervisions with all staff present. The Program Director will continue to monitor clinical charts, to confirm documentation is compliant.
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715.9(a)(2) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(2) Verify the individual 's identity, including name, address, date of birth, emergency contact and other identifying data.
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Observations
Based on a review of 9 applicable client records, the facility failed to obtain documentation to verify the client's identity during the intake process and prior to the administration of a narcotic agent in 1 client record.
Outpatient client #3 was admitted on 12/11/18 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
715.9(a)(2) Intake
Effective immediately, intake staff will verify the individual's identity, including name, address, date of birth, emergency contact and other identifying data. Intake staff will obtain a copy of persons served driver's license or state ID. Nursing staff will ensure that identity is verified prior to administering a narcotic agent. The program director will monitor compliance via quarterly chart audits.
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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 a review of 6 outpatient client records, the facility failed to provide a complete client record in 2 client records.
Outpatient client #5 was admitted on 11/21/16 and was discharged on 10/30/17. The client record did not contain any documentation of follow-up information as of the date of the inspection.
Outpatient client #6 was admitted on 3/3/17 and was discharged on 10/25/17. The client record did not contain any documentation of follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.93 Client Records
By March 1, 2018 staff will receive training around completing aftercare follow up calls. All aftercare follow up calls will be documented in the clinical record. The Program Director will continue to monitor clinical charts, to confirm documentation is compliant.
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