INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 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, PA Treatment & Healing 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
During the annual licensing inspection on August 9, 2016, the facility failed to ventilate the bathroom by an exhaust fan or window.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director met with the Clinical Supervisor and Facility Director immediately after inspection to review the errors in the physical site inspection. Clinical Supervisor is currently collecting 3 bids from three different construction companies as is agency policy. Construction will commence once a construction company has been secured and completion of all construction will be done at the latest by September 19th, 2016. This regulation will be in compliance no later than September 19th, 2016 |
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 obtain an informed and voluntary consent from the client prior to the disclosure of information in eight of eight client records reviewed during the annual licensing inspection on August 9, 2016.
Client #1 was admitted to treatment on 2-23-2016 and was discharged on 5-3-2016. Release of information forms to Probation, a funding source, and the jail signed on 2-23-2016 do not indicate a relevant purpose for disclosure.
Client #2 was admitted to treatment on 3-9-2016 and was discharged on 6-23-2016. Release of information form to a funding source signed on 3-9-2016 allows for the disclosure of information that exceeds the parameters of 255.5.
Client #3 was admitted to treatment on 12-10-2015 and was discharged on 7-11-2016. Release of information forms to a funding source and a laboratory do not include specific information to be disclosed. Release of information form to a funding source allows for the disclosure of information that exceeds the parameters of 255.5. All release forms were signed on 12-10-2015.
Client #4 was admitted to treatment on 2-22-2016 and was discharged on 6-23-2016. Release of information form to Probation does not indicate a relevant purpose for disclosure. Release of information forms to a funding source and a laboratory, does not include specific information to be disclosed. All release forms were signed on 2-22-2016.
Client #5 was admitted to treatment on 2-9-2016 and was discharged on 6-9-2016. Release of information form to Children and Youth Services does not have a relevant purpose for disclosure. Release of information form to a laboratory does not include specific information to be disclosed. Release of information form to the funding source did not indicate a relevant purpose for disclosure or the specific information to be disclosed. Releases of information were signed on 2-9-2016. Release of information form to a physician signed on 3-1-2016 does not have a relevant purpose for disclosure.
Client #6 was admitted to treatment on 2-2-2016. Release of information form to a laboratory does not include specific information to be disclosed.
Client #7 was admitted to treatment on 5-18-2016. Release of information forms to Children and Youth Services and the Probation Department do not have a relevant purpose for disclosure. Release of information form to laboratory does not include specific information to be disclosed. Release of information form to the funding source did not indicate the specific information to be disclosed.
Client #8 was admitted to treatment on 3-10-2016. Release of information form to a laboratory does not include specific information to be disclosed.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director met with the
Clinical Supervisor, Clinical Staff and Facility Director immediately after inspection to review the errors in completing the agency's Release of Information. The standardized purpose on the 255.5 release has been updated to allow staff to select a purpose specific to the entity that information is being released. The Release of information form to the laboratory was also updated to specify solely the specific information that is being disclosed. The Facility Director, Clinical Supervisor and Clinical Staff were re-trained by the Project Director on the agency's policy and procedure for the Release of Information. The Project Director will review and re-train the rest of the agency staff on the proper policy and procedure for the Release of Information at our next scheduled clinical meeting. Updated releases will be obtained for clients number 6,7 and 8 at their next scheduled appointments. This regulation is now in compliance and ongoing compliance will be assured through quality reviews by the Clinical Supervisor, Facility and Project Director, supervision and ongoing training.
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709.93(a) 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:
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Observations
The facility failed to provide a medication record in three of eight client records reviewed on August 9, 2016. Client records # 5, 6, and 8 did not have a medication record documented.
The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director met with the
Clinical Supervisor, Clinical Staff and Facility Director immediately after inspection to review the errors in completing the agency's Medication Log. The Facility Director and Clinical Supervisor and Staff were
re-trained by the Project Director on
the agency's policy and procedure
for completion of the medication log. The Project Director will review and
re-train the rest of the agency staff
on the proper policy and procedure
for the Medication Log at our next scheduled clinical meeting. This
regulation is now in compliance and
ongoing compliance will be assured
through quality reviews by the Clinical Supervisor Facility and Project Director, supervision and ongoing training. |