INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 25, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, New Freedom Recovery Center, LLC 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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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to document a 2017 annual individual performance evaluation in four of four personnel records reviewed on September 25, 2018. Annual evaluations were required, but not documented, for personnel records # 1, 2, 3 and 4. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PROJECT DIRECTOR HAS INSURED THAT ALL ANNUAL EMPLOYEE PERFORMANCE EVALUATIONS WILL BE DONE ON AN ANNUAL BASIS AS IN ACCORDANCE WITH 709.26 (B)(3) LICENSURE PERSONNEL MANAGEMENT. ALL EVALUATIONS WILL BE REVIEWED WITH EMPLOYEE AND SIGNED BY THE EMPLOYEE AND PROJECT DIRECTOR.
HUMAN RESOURCE MANAGER WILL MAKE SURE ALL EVALUATIONS ARE COMPLETED AND FILED ON AN ANNUAL BASIS. |
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.
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Observations
The facility failed to ensure that information released to an employer was compliant with 4 Pa Code 255.5(a)(6) in one of seven records reviewed on September 25, 2018. Client record # 5 documented a consent to release to an employer. The consent allowed for the release of information that exceeded whether of not the client was in treatment. A letter to the employer, dated January 15, 2018, contained information that exceeded whether or not the client was in treatment. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
PROJECT DIRECTOR, CLINICAL SUPERVISOR AND ADMINISTRATIVE ASSISTANT MET WITH ALL CLERICAL STAFF MEMBERS TO REVIEW THE CLIENT CONSENT TO EMPLOYER. PROJECT DIRECTOR, CLINICAL DIRECTOR AND THE ADMINISTRATIVE ASSISTANT WILL ENSURE THAT ANY INFORMATION RELEASED TO EMPLOYERS WILL BE WHETHER OR NOT THE CLIENT IS IN TREATMENT. |