INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 14 through 15, 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 December 12, 2006.
|
Plan of Correction
|
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
The facility did not have hot water available at the time of the inspection.
|
Plan of Correction
Amha will submit a request in writing to the building owner to have the hot water fixed and indicate that this is needed to be in compliance with State regulations. The Executive Director will be responsible for this task and for follow-up. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Fire drill documentation was missing for May, July and October 2006.
|
Plan of Correction
The Safety Committee will schedule all monthly fire drills at their December 2006 meeting. The Safety Committee Chairperson will be responsible for this task and for ensuring that the drills are completed at scheduled. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
The number of participants and exit route used for several of the fire drills was missing. The identification of the primary exit route used was not consistent, sometimes documented as "front" and other times as "1".
|
Plan of Correction
The form used to document drills was reviewed and found to contain all elements necessary to meet this regulation. Completion of the form was found to be inconsistent. This was made known to the new Safety Committee Chairperson and the Committee member responsible for completing the form. The need to document the number of participants and the exits used during the drill was reinforced. The exits used are to be identified as either "front" or "back" as there are two exits from the facility. The Safety Committee Chairperson will be responsible for monitoring completion of the drill forms. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
|
Observations
Documentation that employees have been made aware of the their rights was not provided.
|
Plan of Correction
The Employee Orientation form will be revised to include acknowledgement that employees have been made aware of their rights. This form is reviewed annually with staff so existing employees will also acknowledge that they have been made aware of their rights. The Administrative Assistant will modify the form and the Executive Director will be responsible for seeing that the form is changed and the new version utilized. |
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:
|
Observations
The policy and procedure manual contains "duty to warn" language.
There is language in the HIPAA policy stating the project is not required to agree to a client's request to restrict information released.
The client consent to treatment states written consent is needed except for medical emergencies or to secure payment from health insurance companies or medical plans. Health insurance companies and medical plans are restricted to 4 Pa. Code 255.5.
|
Plan of Correction
AMHA will revise it's policy and procedures related to confidentiality. We will remove "duty to warn" language and list only those nine exceptions that allow for the release of information without written consent from a patient.
We will aslo revise our HIPAA policy to state that we are required to agree to a client's request to restrict information released.
Finally, we will revise our consent to treatment form and remove the health insurance companies and medical plans from the exceptions. All clients will sign a release of information form at intake for their insurance company to secure payment for services. Information to be released will be restricted to that information set forth in 4 Pa. Code 255.5.
The Clinical Coordinator will be responsible for these tasks. |
709.28(c)(2) 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:
(2) Specific information disclosed.
|
Observations
Specific information to be released was missing or unclear in seven of eleven client records reviewed, #1, 2, 3, 4, 5, 7 and 11. A consent to release information form in client record #3 exceeded that permitted under 4 Pa. Code 255.5.
|
Plan of Correction
A staff meeting will be held on 12/7/06 to review the deficienies found during the licensing visit. Proper completion of a consent to release information form will be reviewed with staff. Staff will be instructed to list the specific information to be released on the form. Consent forms will be reviewed for proper completion during random chart reviews which are done as a function of our Quality Improvement Committee. The Clinical Coordinator will be responsible for the staff education and monitoring of appropriate completion of the documentation. |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
The reasons for treatment were not clearly defined in five of nine client records reviewed, #10, 11, 12, 14 and 15. The services offered were not documented in four of nine client records reviewed, #10, 11, 14 and 15.
|
Plan of Correction
A staff meeting will be held on 12/7/06 to review the deficiencies found during the licensing visit. Proper completion of discharge summaries will be reviewed. Specific attention will be paid to the sections related to the client's reasons for for entering treatment and the services offered while in treatment.
The Clinical Coordinator will be responsible for the staff education and for monitoring appropriate completion of the documentation. |