INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25-28, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 25, 2007.
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Plan of Correction
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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 shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The facility failed to provide for a confidentiality policy and procedure consistent with applicable regulations. The confidentiality policy did not address 4 Pa. Code subsection 255.5 in its entirety. The policy needs to address this section of the law in its entirety.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
The facility failed to obtain consents to release information forms from the clients for all releases of information. Consents were not documented for family members who participate in group sessions. A consent to release information form must be on file for each release .
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30(1) LICENSURE Client Rights
709.30. Client rights.
(1) A person receiving care or treatment under section 7 of the act (71 P. S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to ensure that clients retained their civil rights while in treatment. Agency policy indicated that client phone calls are monitored on Speakerphone by facility staff and that facility staff may terminate phone calls if the staff person deems the subject matter to be inappropriate. This violates the client right to privacy.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(1) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication.
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Observations
The facility has failed to comply with with regulations regarding the administration of medication. Agency policy stated that peer caregivers may administer medications to the children of another woman in her absence if a written consent is on file to identify the caregiver. This regulation requires that licensed personnel are the only ones who may administer medication.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
The facility failed to maintain complete and accurate records on the administration of medication. Medication log sheets frequently documented missed doses of medication, but provided no explanation as to why the dose was not administered.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
The facility failed to provide for complete medical histories in four of the client records reviewed. Medical histories were incomplete in client records # 3, 4, 5 and 6. Family medical histories were missing.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
The facility failed to document physical exams where the person conducting the exam was clearly identified. Physical exams did not have signatures which verified that a physician had conducted the exam. Electronic signatures were used and no title accompanied the name of the individual completing the exams . It could not be determined if the exams were done by Physicians, CRNP's or Physician Assistants in client records # 3, 5 and 6. The physical was not completed in the required 7 days in client record # 3.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to provide for complete psychosocial evaluations in client records # 1, 2, 4 and 5. The evaluations often failed to address support systems, coping mechanisms and the clients' attitudes toward treatment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
The facility failed to provide for complete discharge summaries. Reasons for treatment and the clients' responses to treatment were not consistently addressed in client records # 2, 3 and 4.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
The facility failed to document that work done by residents at or for the facility was work therapy. Clients were not paid for this work. Documentation of individualized treatment goals verifying that work was part of the therapy was missing or incomplete in client records # 1, 2, 4 and 5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |