INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 11 and 12, 2006 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 October 10, 2006.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Training feedback was not consistently documented.
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Plan of Correction
Clinical Supervisor will maintain a
log-in tracking sheet on trainings and will cross check that training feedback forms are completed. This documentation will ensure compliance.
Program Director will monitor. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
The women's lavatory in the rear of the facility did not have a window or a working exhaust fan.
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Plan of Correction
New exhaust fan has been installed to ventilate bathroom properly |
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
The documentation of fire safety training was on file, but had not been provided within 7 days of the date of hire for some of the staff. Fire safety training for new employees must be done within seven days of hire.
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Plan of Correction
A form has been developed to provide documentation of training upon hire. Program Director and Health and Safety Captain will monitor to ensure compliance. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Training to ensure that all personnel on all shifts are prepared to perform assigned tasks during emergencies did not consistently occur on a timely basis. Training must occur within seven days of hire for all new staff.
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Plan of Correction
All new hires will recieve a Health and Safety package upon hire. Program Director will monitor to ensure compliance. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
No financial statement of income and expenses was included in the annual report.
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Plan of Correction
A finincial statement of income and expenses will be made available. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
No documentation was presented to demonstrate that the Governing Body and the Project Director collaborated on the formulation of goals and objectives with final approval given by the Governing Body.
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Plan of Correction
Will be documented in Board of Directors Meeting Minutes. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
A performance report on the project goals and objectives is recommended quarterly but required on at least an annual basis. The report is to be done as part of the Project Director's responsibilities and in conjunction with the Board. Documentation should include a review of the goals and objectives. No report on the goals and objectives for the year just ended was presented at the time of the inspection.
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Plan of Correction
Will be reviewed annually and will be demonstrated in the Management Report. Project Director will monitor to ensure compliance. |
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 agency policy on client confidentiality was incomplete and contained inaccurate information. The language in the policies and procedures did not distinguish between HIPAA and 42 CFR Part 2, Subparts A through E. The content of the policy and procedure gives the impression that the Project does not recognize the distinctions in the various applicable laws and regulations. The requirements of this regulation stipulate that written procedures comply with 4 Pa. Code subsection 255.5. The procedures as presented at the inspection address only subpart (b) of subsection 255.5. The patient confidentiality notice form incorrectly states that revocations must be put in writing by the client. This is incorrect. Clients may revoke consents to release information verbally and staff must then document the revocation in the client record. This notice also incorrectly states that client information can be released without consent to obtain legal or financial services or to another medical facility. The same form also states that Discovery House need not agree to any restrictions on disclosures of information requested by the client. All releases of information must be voluntary unless otherwise excepted by the applicable section of 42 CFR. The section of the confidentiality procedure entitle "Prohibition on Redisclosure" on page 191 of the manual is blank.
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Plan of Correction
Policy will be amended to reflect distinctions between 42 CFR Part 2 and HIPAA regulations. Forms will be changed to comply with cited regulations. Program Director will monitor to ensure compliance. |
709.28(a)(2) 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:
(2) Staff access to client records.
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Observations
The Discovery House policy on staff access to client records lacked sufficient detail. The policy should identify by name or position who may access files. The method of access should be outlined. Since the project has an electronic system for keeping client identifying information, a detailed policy and procedure which addresses all of the requirements of the Licensing Alert of May, 2005 relating to Electronic Clinical records must be developed.
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Plan of Correction
Policy will be amended to include language regarding access restriction. An attachment will be available that details by position. |
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
One agency form presented did not comply with the intent of this regulation. The form entitled "Patient Agreement to Pay for Treatment If Third Party Coverage is denied" contains language which indicates information will be released but the form does not specify what specific information will be sent to third party sources. This constitutes a general consent to release information which does not comply with the requirements of the law.
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Plan of Correction
Form will be changed to comply with regulation. Program Director will monitor to ensure compliance. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Personal histories should collect as much personal information about a client as possible since they form the basis from which the psychosocial evaluation and subsequent treatment plans are formulated. Personal histories in client records reviewed did not consistently detail relevant information.
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Plan of Correction
Responsible Medical Staff has been trained in proper procedure for completing the form. Program Director will monitor to ensure compliance. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The psychosocial evaluation did not contain evaluative summaries of the client's historical data compiled in client records (#1, 3, 4, 5, 6, 9). The evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
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Plan of Correction
There will be regular training on psychosocial evaluation. Clinical Supervisor will monitor to ensure compliance. |
709.93(a)(3) LICENSURE Client records
709.93. 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:
(3) Record of services provided.
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Observations
Records of service were not complete in client records reviewed. Inaccurate or incomplete information was noted in client records # 2, 3, 7, 9 and 10.
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Plan of Correction
Regular qualitative and quantitative reviews will be conducted. Clinical Supervisor will monitor to ensure compliance. |