INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 27 - 28, 2013 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, Persad Center, 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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705.28 (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.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record including the exit route used and whether the fire alarm or smoke detector was operative. In addition, the facility failed to document a fire alarm or smoke detector was set off during each fire drill and failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill records for August 2012 through August 2013 were reviewed on August 27, 2013.
The facility failed to maintain a fire drill record including the exit route used and whether the fire alarm or smoke detector was operative for the following fire drills: 8/16/12, 9/18/12, 12/19/12, 2/8/13, 3/18/13, 4/17/13, 7/16/13, 8/15/13.
The facility failed to document a fire alarm or smoke detector was set off during the following fire drills: 8/16/12, 9/18/12, 12/19/12, 2/8/13, 3/18/13, 4/17/13, 7/16/13, 8/15/13.
The facility failed to document the use of alternate exits for the following fire drills: 8/16/12, 9/18/12, 12/19/12, 2/8/13, 3/18/13, 4/17/13, 7/16/13, 8/15/13.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
Plan of Correction: Fire Safety
The fire drill record has been modified (as of 9/23/13) by the Executive Director to collect the required information regarding what exit route is used, which fire alarm/detector was set off and whether it was operable and to indicate which exit was used during the drill. Previously, the record indicated what exit had been blocked during the simulation and where the fire simulation was originated. While this was our indicator of which alarm was pulled, this was not clear and is now made clear by the revised form.
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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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when disclosing client information in five of five client records. In addition, the facility failed to obtain a written, informed and voluntary consent from the client prior to the release of information contained in the client record in one of six client records
The findings include:
Eight client records were reviewed on August 27 - 28, 2013. Six client records were reviewed for informed and voluntary consents from the client. The facility exceeded the limitations imposed at 4 Pa. Code 255.5 when releasing information to a funding entity in client records # 1, 5, 6, 7 and 8. The facility failed to obtain a written, informed and voluntary consent from the client prior to the release of information in client record # 2.
Client # 1 was admitted into treatment on December 7, 2012 and discharged on August 26, 2013. Client record # 1 included a consent to release information to a funding entity dated December 7, 2012. This consent to release information indicated medication information would be released to the funding entity which exceeded the limitations imposed at 4 Pa. Code 255.5. Client record # 1 included a consent to release information to the probation officer dated January 15, 2013. This consent to release information indicated a discharge summary would be released to the probation officer which exceeded the limits imposed at 4 Pa. Code 255.5.
Client # 2 was admitted into treatment on April 2, 2013 and discharged on June 14, 2013. Client record # 2 included documentation that a funding entity was billed for services on April 2, 2013. There was no documentation that a written, informed and voluntary consent was obtained from client # 2 prior to this disclosure to the funding entity.
Client # 5 was admitted into treatment on June 4, 2013. Client record # 5 included a consent to release information to a funding entity dated June 4, 2013. This consent to release information indicated medication information would be released to the funding entity which exceeded the limitations imposed at 4 Pa. Code 255.5.
Client # 6 was admitted into treatment on July 18, 2012. Client record # 6 included a consent to release information to a funding entity dated January 22, 2013. This consent to release information indicated medication information would be released to the funding entity which exceeded the limitations imposed at 4 Pa. Code 255.5.
Client # 7 was admitted into treatment on February 22, 2013. Client record # 7 included a consent to release information to a funding entity dated February 22, 2013. This consent to release information indicated medication information would be released to the funding entity which exceeded the limitations imposed at 4 Pa. Code 255.5.
Client # 8 was admitted into treatment on January 24, 2013. Client record # 8 included consents to release information to a funding entity dated January 24, 2013 and February 25, 2013. These consents to release information indicated medication information would be released to the funding entity which exceeded the limitations imposed at 4 Pa. Code 255.5.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Program Director updated the release of information forms used for billing to ensure compliance with 4 PA Code 255.5. The updated form will be implemented on August 29, 2013. the newe form will be completed for all active clients by October 15, 2013.
The Program Director will provide a training update for clinical and billing staff on confidentiality laws, DDAP's interpretive guidelines, and policies and procedures for the request and release of confidential information in the staff meeting on October 7, 2013. Persad Center will be in compliance with this standard by October 7, 2013
The Program Director will conduct a targeted chart review in December 2013 and March 2014 to ensure that this standard is met.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that included the proposed type of support service in four of five client records.
The findings include:
Eight client records were reviewed on August 27 - 28, 2013. Five client records were reviewed for individual treatment plans including the proposed type of support service. The facility failed to document the proposed type of support service in client records # 1, 2, 5, and 8
Client # 1 was admitted into treatment on December 7, 2012 and discharged on August 26, 2013. The individual treatment and rehabilitation plan for client # 1 was completed on December 7, 2012 and did not include documentation of the proposed type of support service.
Client # 2 was admitted into treatment on April 2, 2013 and discharged on June 14, 2013. The individual treatment and rehabilitation plan for client # 2 was completed on April 2, 2013 and did not include documentation of the proposed type of support service.
Client # 5 was admitted into treatment on June 4, 2013. The individual treatment and rehabilitation plan for client # 5 was completed on June 10, 2013 and did not include documentation of the proposed type of support service.
Client # 8 was admitted into treatment on January 24, 2013. The individual treatment and rehabilitation plan for client # 8 was completed on January 24, 2013 and did not include documentation of the proposed type of support service.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
1- The Clinical Supervisor will train the clinical staff to ensure understanding on all of the standards of comprehensive treatment planning on September 23, 2013.
2- The Clinical Supervisor and the Quality Assurance team of clinicians will conduct a chart review of all D&AQ charts target inclusion of support services by December 15, 2013.
3- The Clinical Supervisor will conduct a follow-up review of all D&A charts by March 15, 2014.
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 60 days in five of six client records.
The findings include:
Eight client records were reviewed on August 27 - 28, 2013. Six client records were reviewed for treatment plan updates. The facility failed to document treatment plan updates every 60 days in client records # 1, 2, 6, 7 and 8.
Client # 1 was admitted into treatment on December 7, 2012 and discharged on August 26, 2013. The comprehensive treatment plan was completed on December 7, 2012. Treatment plan updates were due to be completed no later than February 7, 2013, April 7, 2013, June 7, 2013 and August 7, 2013. There was no documentation of any treatment plan updates in client record # 1.
Client # 2 was admitted into treatment on April 2, 2013 and discharged on June 14, 2013. The comprehensive treatment plan was completed on April 2, 2013. A treatment plan update was due to be completed no later than June 2, 2013. There was no documentation of any treatment plan updates in client record # 2.
Client # 6 was admitted into treatment on July 18, 2012. The comprehensive treatment plan was completed on July 18, 2012. Treatment plan updates were due to be completed no later than September 18, 2012, November 18, 2012, January 18, 2013, March 18, 2013, May 18, 2013 and July 18, 2013. Treatment plan updates were not completed until October 8, 2012, December 4, 2012, March 1, 2013, May 1, 2013 and July 24, 2013.
Client # 7 was admitted into treatment on February 22, 2013. The comprehensive treatment plan was completed on February 22, 2013. Treatment plan updates were due to be completed no later than April 22, 2013, June 22, 2013 and August 22, 2013. Treatment plan updates were not completed until April 24, 2013 and July 5, 2013.
Client # 8 was admitted into treatment on January 24, 2013. The comprehensive treatment plan was completed on January 24, 2013. Treatment plan updates were due to be completed no later than March 24, 2013, May 24, 2013 and July 24, 2013. Treatment plan updates were not completed until April 15, 2013 and June 24, 2013.
The clinical supervisor was interviewed throughout the inspection and confirmed the findings.
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Plan of Correction
1- The Clinical Supervisor will train the clinical staff to ensure understanding on the standards of treatment planning and review, including the timeliness of treatment planning and reviews, on September 23, 2013.
2- The Clinical Supervisor and the Quality Assurance team of clinicians will conduct a chart targeted chart review focusing on timeliness of treatment plans and treatment plan reviews by December 15, 2013.
3- The Clinical Supervisor will conduct a follow-up review of all D&A charts by March 15, 2014.
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