INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 28, 2016 through November 30, 2016 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, Crisis Management 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:
|
Plan of Correction
|
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.
|
Observations
Based on a physical plant inspection conducted on November 29, 2016 at approximately 11:00 A.M., it was discovered that the facility failed to ensure that the rear emergency exit from the facility, which is one of two exits, was unobstructed at all times. More specifically, the door is maintained as locked except when the emergency response system is activated or the door is manually unlocked with a key. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
709.10 (a)(1)(i)
The locking mechanism to the door at the rear emergency exit of the facility will be changed in order to offer an unobstructed exit from the facility.
While the door will remain locked, a highly visible button that automatically unlocks the door will be placed on the wall near the door.
Pressing this button will automatically open the door. It will set off an internal alarm that alerts staff that someone is leaving the River's Bend Facility. This mechanism will not automatically set off the fire alarm system. A separate fire alarm alert system will also be located at the rear emergency exit of the River's Bend Facility.
The Project Director and Facility Director will oversee the installation and testing of the above rear emergency exit system.
OTHER: Response to the most recent rejection concerning Observation P105: The Fire alarm, when pulled or set off, will automatically disengage the locks for all doors on the unit and will automatically call the fire department.
|
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.
|
Observations
Based on a review of patient records, the facility disclosed information prior to the patient signing an informed and voluntary consent to release form or disclosed information beyond the parameters of the patient-signed release form in patient record #'s 2, 8, 12, and 15. Additionally, patient records # 7, 9, and 13 had consent to release information forms that were missing the purpose of the disclosure. Patient #2 was admitted on 10/19/16 and was active at the time of inspection. The record contained a consent to release information form to a government official signed on 10/31/16, which only authorized the facility to disclose the patient's presence in treatment. However, the record contained documentation of a facsimile which also identified the nature of the program. Patient #7 was admitted on 1/26/16 and was discharged on 3/22/16. A consent to release form to a probation officer, signed and dated on 3/10/16, did not include the purpose of disclosure.Patient #8 was admitted on 5/13/16 and discharged on 7/12/16. There was documentation that a consultation with another treatment provider disclosing the patient's presence in treatment and nature of the program on 5/26/16, 6/3/16, 6/8/16, 6/10/16, and 6/24/16; however, the patient record did not contain a patient-signed release of information form at the time of the inspection. Additionally, a progress note from 5/23/16 documented counselor contact with a family member of the patient, however, a consent to release information form was not signed and dated by the patient until 7/1/16.Patient #9 was admitted on 2/18/16 and discharged on 3/18/16. The record contained consent to release information forms to two family members, signed and dated on 2/19/16, which did not include the purpose of disclosure.Patient #12 was admitted on 6/27/16 and discharged on 7/20/16. The patient record contained documentation that the facility attempted to receive reimbursement from a funding source covering 6/27/16 through 7/15/16; however, the patient record did not contain a patient-signed release of information form for the funding source at the time of inspection. Patient #13 was admitted on 3/28/16 and was discharged on 4/30/16. A consent to release information form to a personal associate, signed and dated on 3/28/16, did not include the purpose of disclosure.Patient #15 was admitted on 12/17/15 and discharged on 2/24/16. There was documentation of a consultation with another treatment provider on 2/19/16; however, the patient record did not contain a patient-signed release of information form for the other treatment provider at the time of the inspection. The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
709.28 ©
A new consent to release information form has been developed and will be implemented once staff have been trained.
The Project Director will conduct a training in all aspects of client confidentiality, particularly as to how they apply to the proper use of the consent to release information.
The Facility Director will conduct weekly reviews of all charts to insure that the release of information is being used in the proper fashion and that all signatures and dates are present and within the time frame allotted by the regulations.
The Project Director will conduct unannounced independent chart audits to review for the utilization and correct application of the consent to release information form.
|
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
|
Observations
On November 28, 2016, the facility's Unusual Incident Reporting policy was reviewed and it was discovered that the facility failed to develop and implement, in their policy and procedures, a response to three of the eight unusual incidents. The three incidents not included are 1) selling or use of illicit drugs on the premises, 2) any significant disruption of services that would close the facility for more than 1 day, and 3) outbreak of a contagious disease requiring Centers for Disease Control notification.These findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
709.34(a)
It will be the policy of the River's Bend 3B Residential Treatment Program for the Facility Director to ensure that an unusual incident report is completed on the following unusual incidents:
1)Physical assault or sexual assault by staff or a client.
2)Selling or use of illicit drugs on the premises
3)Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
4)Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
5)Theft, burglary, break-in or similar incident at the facility.
6)Event at the facility requiring the presence of police, fire or ambulance personnel.
7)Fire or structural damage to the facility.
8)Outbreak of a contagious disease requiring Centers for Disease control (CDC) notification.
The Facility Director will utilize all staff who were witness to or who are capable of providing information regarding the unusual incident.
The Facility Director will immediately notify the Project Director of the incident. Based on the nature of the serious incident, the Project Director will consult with the Agency Medical Director and/or Chief Operating Officer to determine the next course of action.
The Facility Director will review the unusual incident report for accuracy and provide a final sign off.
The Facility Director will re-train all staff in the proper mechanisms of completing an unusual incident report and the circumstances which qualify for the completion of an incident report.
|
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
|
Observations
On November 28, 2016, the facility's Unusual Incident Reporting policy was reviewed and it was discovered that the facility failed to include four of five unusual incident response procedures. The four procedures not included in the policy are 1) prompt review and identification of the causes for the unusual incident, 2) implementation of a timely and appropriate corrective action plan, when applicable, 3) ongoing monitoring of the corrective action plan, and 4) reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with applicable confidentiality laws.These findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
709.34(b)(2)
It will be the policy of the Crisis Management Services to have the Project Director and Facility Director of the River's Bend Program review the documentation included in the actual incident report along with all other available consumer records and possible statements taken from witness to the incident within 24 hours of incident.
The Project Director and Facility Director will identify the causes, both direct and indirect that potentially led up to the incident.
Where appropriate and indicated, a plan of correction will be developed and put into place within 72 hours of the incident.
The Project Director and Facility Director will monitor the corrective action plan initially, on a weekly basis for the first three months, then on a quarterly basis, to insure that the plan is operating effectively.
In all of the systems and mechanisms described above, the Project Director and Facility Director will ensure that the reporting of unusual incidents, to any entity, is in compliance with all State and Federal Confidentiality laws.
|
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
On November 28, 2016, it was discovered that there were 16 incidents requiring the presence of police or ambulance personnel from January 2016 to November 2016. The dates of the incidents requiring emergency personnel at the facility were 1/12/16, 2/10/16, 2/19/16, 3/25/16, 4/19/16, 4/21/16, 5/16/16, 5/19/16, 5/20/16, 5/27/16, 6/7/16, 8/26/16, two incidents on 9/6/16, 10/6/16, and 11/25/16. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory timeframe for any of the incidents.These findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
709.34 (c)
To the extent permitted by State and Federal confidentiality laws, the project Director shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
1)Physical or sexual assault by staff or a client.
2)Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
3)Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
4)Event at the facility requiring the presence of police, fire or ambulance personnel.
5)Outbreak of a contagious disease requiring CDC notification.
The Facility Director will re-train all staff in the proper mechanisms of completing an unusual incident report and the circumstances which qualify for the completion of an unusual incident report.
Resubmission of the plan of correction as a result of the most recent rejection: The Facility Director will review the 16 incidents where an incident report had not been completed and sent to the Department of Drug and Alcohol Programs.
The Facility Director will insure that the 16 incident reports have been completed and that they correspond with documentation in the client's chart.
The 16 incident reports will be sent directly to the Department of Drug and Alcohol Programs.
|