INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Schuylkill Health System Center for Counseling Services 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 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that each bathroom is maintained in a functional manner at all times.
The findings include:
A physical plant inspection was conducted on 4/23/2015 at approximately 2:45 PM.
The sink in the staff bathroom drained water excessively slow as it was clogged at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Work Order submitted to have problem corrected.Responsible Person: Program Director Date: 4/24/15
2.Inform staff to report any future problems to the program director so that corrective action is initiated immediately. Responsibility: Staff and Program Director Date: 5/4/15.
3. Program Director to initiate a plan of preventive monitoring monthly to insure ongoing compliance. Responsible Person; Program Director. Date: Monthly beginning in May 2015 reevaluate as indicated. |
711.93(c)(2)(i) LICENSURE Name of person/agency/organization
711.93. Client records.
(c) Confidentiality.
(2) 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:
(i) The name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that includes all of the required content required by regulation in one of ten client records reviewed.
The findings include:
Ten client records requiring informed and voluntary consent to release information forms were reviewed on 4/23/2015. The facility failed to document the name of the organization on an informed and voluntary consent to release information form in client record # 5.
Client # 5 was admitted to the outpatient facility on 7/29/2014. Client # 5's informed and voluntary consent to release information to the client's funding source dated 7/29/2014 listed the name of the funding source as "PPO". The actual name of the client's funding source, Highmark Blue Cross Blue Shield, was not identified on the consent to release information form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1.Identify protocol to be followed on insurance verification to insure correct source of payment is identified.Responsible Person: Program Director Date:5/4/15.
2.Inservice all staff on protocol and requirement to identify specific source of funding on consent.Responsiblity: Program Director. Date: 5/11/15
3. Random chart audits monthly to measure compliance as part of bi-weekly clilical supervision meeting with clinical staff.Compliance reported monthly. Responsiblity: Program Director and Clinical Supervisor
Responsiblity: Clinical Supervisor Date: Monthly audits beginning May 2015. |