INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Alcohol and Drug Abuse Services, 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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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to ensure that the exits from the residential facility were unobstructed.
A physical plant inspection of the facility was completed on September 11, 2019. An exit door from the basement was obstructed by a bench seat and could not be opened more than a few inches.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The inpatient supervisor on 9/12/19 met with all inpatient staff and reviewed importance of making sure all exits are unobstructed and all times. A checklist was added to the fire drill forms to include checking all exits with each drill. All staff were trained on this form on 9/12/19. This was recorded in the staff minutes. The inpatient supervisor will monitor the forms and the exits monthly. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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
The facility failed to document a written fire drill record which included whether the fire alarm or smoke detector was operative.
Fire drill logs were reviewed for the period of January 1, 2018 to August 31, 2019 on September 11, 2019. The fire drill logs were missing documentation of whether the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The inpatient supervisor on 9/12/19 met with all inpatient staff and re-educated then on the correct way to fill out the form and reinforcing the importance of checking that the smoke/fire alarm were operative. The inpatient supervisor will review forms monthly for compliance.
On 10/8/19 the inpatient supervisor and the residential supervisor are providing training to all inpatient staff on how to complete every emergency drill. This will be documented in the staff meeting minutes. |
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.
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Observations
The facility failed to document an informed and voluntary consent to release information in one of eight client records.
Eight client records were reviewed on September 11, 2019. Eight records were reviewed for consents to release information. Client record # 6 did not document a consent.
In client record # 6, a letter was sent on August 28, 2019 to a facility. There was no consent to release the information documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
on 9/12/19 the inpatient supervisor re-educated the DATS and Case Managers about the importance of having a consent to release information. Policy was revised on 9/12/19 to include that any letters sent will have the consent attached or clerical are not to send. On 9/19/19 a training on confidentiality and how to complete consents correctly was completed for DATs and Case Managers. The inpatient supervisor will review letters weekly for compliance. The program manager will review monthly to ensure compliance. ON 9/24/19 the DATS who sent the letter contacted Client #6 to inform them of letter sent without consent. |
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
The facility failed to document an informed and voluntary consent to release information that included the information to be released in three of eight client records.
Eight client records were reviewed on September 11, 2019. Eight records were reviewed for consents to release information. Client records # 1, 2 and 3 were missing the required information.
In client record # 1, a release of information was signed on August 15, 2019 for a lawyer. The release did not document the information to be released. A letter was sent to the lawyer on August 15, 2019.
In client record # 2, a release of information to a counseling agency, signed July 8, 2019, did not document the information to be released. A letter was sent to the counseling agency on July 8, 2019.
In client record # 3, a release of information was signed August 26, 2019 for a surgeon. The release did not document the information to be released.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/12/19 the inpatient supervisor reeducated the DATS and Case Managers about the importance of having a consent to release information and how to fill them out correctly. On 9/19/19 a confidentiality training was completed to address how to complete a consent correctly for all DATS and case manager. As the clients from record #1, #2 and #3 were present in the facility on 9/12/19 a correct consent was completed with them. The inpatient supervisor will review files weekly for compliance and the program manager will review monthly for compliance. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to document an informed and voluntary consent to release information that included the purpose in three of eight client records.
Eight client records were reviewed on September 11, 2019. Eight records were reviewed for consents to release information. Client records # 1, 2 and 3 were missing the required information.
In client record # 1, a release of information was signed on August 15, 2019 for a lawyer. The release did not document the purpose. A letter was sent to the lawyer on August 15, 2019.
In client record # 2, a release of information was signed on July 8, 2019 for a counseling agency. The release did not document the purpose. A letter was sent to the counseling agency on July 8, 2019.
In client record # 3, a release of information was signed August 26, 2019 for a surgeon. The release did not document the purpose.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/12/19 the inpatient supervisor reeducated the DATS and Case Managers about the importance of having a consent to release information and how to fill them out correctly. On 9/19/19 a confidentiality training was completed to address how to complete a consent correctly for all DATS and case manager. Specifically documenting the purpose of the consent. As the clients from record #1, #2 and #3 were present in the facility on 9/12/19 a correct consent was completed with them. The inpatient supervisor will review files weekly for compliance and the program manager will review monthly for compliance. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
The facility failed to document an informed and voluntary consent to release information that included the date, event or condition upon which the consent will expire in three of eight client records.
Eight client records were reviewed on September 11, 2019. Eight records were reviewed for consents to release information. Client records # 1, 2 and 3 were missing the required information.
In client record # 1, a release of information was signed on August 15, 2019 for a lawyer. The release did not document an expiration date.
In client record # 2, a release of information was signed on July 8, 2019 for a counseling agency. The release did not document an expiration date.
In client record # 3, a release of information was signed August 26, 2019 for a surgeon. The release did not document an expiration date.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 9/12/19 the inpatient supervisor reeducated the DATS and Case Managers about the importance of having a consent to release information and how to fill them out correctly. On 9/19/19 a confidentiality training was completed to address how to complete a consent correctly for all DATS and case manager. Specifically documenting the expiration date. As the clients from record #1, #2 and #3 were present in the facility on 9/12/19 a correct consent was completed with them. The inpatient supervisor will review files weekly for compliance and the program manager will review monthly for compliance. |