INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24 - 25, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Innovative Recovery Solutions, 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 and a plan of correction is due on September 20, 2010.
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Plan of Correction
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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.
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Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to document the instruction of staff in the use of the fire extinguisher upon staff employment, in four of six personnel records, as required.
The findings include:
Six personnel records were reviewed. Six employees required fire extinguisher training. Per regulation, the nonresidential facility shall instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 1, 2, 5 and 6.
Employees # 1 and 2 are co-founders of the program. The facility began providing services on January 10, 2010. Employees # 1 and 2 did not complete fire extinguisher training until January 27, 2010. Fire extinguisher training was not completed upon staff employment.
Employee # 5 was hired on February 13, 2010. There is no documentation that employee
# 5 completed fire extinguisher training.
Employee # 6 was hired on January 25, 2010. There is no documentation that employee
# 6 completed fire extinguisher training.
The project/facility director was interviewed on August 25, 2010 and confirmed that employees # 5 and 6 had not completed fire extinguisher training.
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Plan of Correction
a. Fire extinguisher training has been completed for Employees #1 and 2 and documentation is in their personnel records. Business Manager will complete the Fire Safety training with both employees #5 and 6 by September 30, 2010 and will place documentation of this training in their personnel records for review. On going, Business Manager will complete Fire Safety training with all new staff members during their orientation to employment with this facility. Documentation will be placed in each individual's personnel record and maintained for review. Facility Director will monitor for compliance. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill logs and an interview with the project/facility director, the facility failed to document the exit routes used during five of six fire drills, as required.
The findings include:
Fire drill logs were reviewed on August 24, 2010. Per regulation, the nonresidential facility shall maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. The facility failed to document the exit route used during five of six fire drills conducted.
On August 24, 2010, the project/facility director was interviewed and confirmed that exit routes had not been documented on five of the fire drills conducted.
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Plan of Correction
Facility Director will update the fire drill record to include an area of notation regarding which exit routes were used for each drill. Facility Director will update the form prior to use for the September fire drill. Facility Director is responsible to maintain documentation related to fire drills and will monitor the documentation for compliance. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs and an interview with the project/facility director, the facility failed to document that alternate exit routes were used during five of six fire drills, as required.
The findings include:
Fire drill logs were reviewed on August 24, 2010. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility failed to document the use of an alternate exit route during five of six fire drills conducted. Only one fire drill documented the exit route used.
On August 24, 2010, the project/facility director was interviewed and confirmed that an alternate exit route had not been documented on the fire drills conducted.
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Plan of Correction
Facility Director will update the fire drill record to include an area of notation indicating which exit routes were used based on the location of the "fire" during each drill. Facility Director will update the form prior to use for the September fire drill. Facility Director is responsible to maintain documentation related to fire drills and will monitor the documentation for compliance. |
709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to document the results of a reference investigation in two of four personnel records, as required.
The findings include:
Six personnel records were reviewed on August 24 - 25, 2010. Four personnel records required reference investigations. Per regulation, the personnel records shall include the results of reference investigations. Personnel records # 5 and 6 did not include the results of a reference investigation.
Employee # 5 was hired on February 13, 2010. There was no documentation of a reference investigation in personnel record # 5.
Employee # 6 was hired on January 5, 2010. There was no documentation of a reference investigation in personnel record # 6.
The project/facility director was interviewed on August 24, 2010 and confirmed there were no reference investigations documented for employees # 5 and 6.
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Plan of Correction
Business Manager will complete reference investigations for Employees #5 and 6 by September 30, 2010 so that the information is available for review. On going, the Business Manager will be responsible for completing reference investigations for all new employees and will complete and maintain the documentation of this investigation in the personnel records. Facility Director will monitor for compliance. |
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 and an interview with the project/facility director, the facility documented a consent to release information form that misinformed the client regarding revocations of consent to release information in 10 of 10 client records.
The findings include:
Ten client records were reviewed on August 24 - 25, 2010. Ten client records were required to include an informed and voluntary consent to release patient identifying information. Ten client records included consents to release information that included a revocation statement. This revocation statement indicated that the client had to submit the revocation of the consent in writing. This statement is not consistent with the federal regulations at 42 CFR Part 2, Subpart C, Subsection 2.31 (c) (3) which states that a facility may not act in reliance of a consent that is known to have been revoked. The facility must accept verbal revocations of client consent to release information and must then document the clients's verbal revocation. The facility failed to provide the clients with an informed and voluntary consent, as a result of the misinformation, in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.
The project/facility director was interviewed on August 25, 2010. The project/facility director reviewed the consents and confirmed that the revocation statement was incorrect.
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Plan of Correction
Facility Director will remove the "in writing" statement from all revocation statements on our forms. Facility Director will destroy all existing copies of consents and provide new forms and ensure that all master forms are updated. Documentation of the updated forms will be kept on file for review and Facility Director will monitor for on going compliance. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records and an interview with the project/facility director, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the specific information to be disclosed in one of two client records, as required.
The findings include:
Ten client records were reviewed on August 24 - 25, 2010. Two client records included releases to the probation officer and were reviewed for the specific information disclosed. Per regulation, 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 specific information disclosed. The facility released specific client information that exceeded the limits imposed by 4 Pa. Code 255.5 in client record # 4.
Client # 4 was admitted to the program on April 1, 2010. On June 10, 2010 a letter was sent to the probation officer which released the results of urine tests and listed the patient's current dosage of methadone. This specific client information released exceeded the limits imposed by 4 Pa. Code Subsection 255.5 (b).
The project/facility director was interviewed on August 25, 2010. The project/facility director also confirmed the letter sent to the probation officer, of patient # 4, included information that exceeded 4 Pa. Code 255.5 (b).
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Plan of Correction
Facility Director will provide in house training related to the limitations of 255.5 as related to release of information from patient's records. Documentation of this training will be maintained as part of each employee's record. Facility Director will ensure on-going compliance by training each new staff member and maintaining the documentation. |
709.92(a)(1) 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records and an interview with the project/facility director, the facility failed to document a treatment plan with long term treatment goals in four of eight clients records, as required.
The findings include:
Ten client records were reviewed on August 24 - 25, 2010. Eight client records included treatment plans which required long term treatment goals. Two client records were new admissions and treatment plans were not yet due. Per regulation, an individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of short and long term goals for treatment as formulated by both staff and client. The facility failed to document long term treatment goals in client records # 1, 3, 8 and 9.
Client # 1 was admitted into treatment on April 1, 2010. A treatment plan was completed on April 3, 2010. The treatment plan did not include long term treatment goals.
Client # 3 was admitted into treatment on March 15, 2010. A treatment plan was completed on March 16, 2010. The treatment plan did not include long term treatment goals.
Client # 8 was admitted into treatment on July 13, 2010. A treatment plan was completed on July 16, 2010. The treatment plan did not include long term treatment goals.
Client # 9 was admitted into treatment on April 9, 2010 and discharged on June 21, 2010. A treatment plan was completed on April 9, 2010. The treatment plan did not include long term treatment goals.
The project/facility director was interviewed on August 15, 2010 and confirmed the treatment plans did not include long term goals.
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Plan of Correction
Clinical staff will work with each patient to formulate long terms goals as related to their personal progress in recovery and will document these goals in the patient's treatment plan. Facility Director will monitor for compliance through random chart audits. |