INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on September 26, 2022 through September 27, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Behavioral Wellness Center at Girard DD/FIR 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that cold food was kept at or below 40 degrees Fahrenheit and frozen food was kept at or below 0 degrees Fahrenheit.
At approximately 12:15 PM on September 27, 2022, the refrigerator temperature was measured at 50 degrees Fahrenheit and the freezer temperature was measured at 10 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
*Clinical Supervisor will review the protocol and procedure with staff on proper refrigerator temperature.
* CRS will maintain a daily log.
*Clinical Supervisor will review the log on a weekly basis.
*Refrigerator and freezer temperature was adjusted to ensure cold food stays at below 40 degrees on September 28 ,2022
* Maintenance will be call when refrigerator temperature changes. Fully compliance by November 1,2022. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) 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 document the name of the person, agency, or organization to whom disclosure is made on consent to release information forms in fourteen of fourteen client records reviewed.
Each client record reviewed contained a release of information form to the "probation and parole department"; however, each form, in every record, did not include the specific name of the person, agency, or organization to whom disclosure would be made.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1.The Probation and Parole release will be updated to require the inclusion of the officer's name or the county/state where the probation is in effect.
a. Responsible party -VP Operation?
Completion date ?11-1-2022
2.All staff will receive in-service training on the accurate completion of the form
a. Responsible party -Clinical
Supervisor-Completion date- 1-15-2022
3.The clinical supervisor will conduct a
60 day focus review to insure that
allforms are accurately completed |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on release of information forms in one of fourteen client records reviewed.
Client # 4 was admitted to the inpatient non-hospital detoxification activity on October 28, 2021 and was discharged on November 1, 2021. The release of information forms to a government agency and the probation department were signed and dated by the client on October 28, 2021, but both forms did not include the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
1.Clinical supervisor will review Client # 4 with assigned counselor (s) to discuss importance of documenting the purpose of the disclosure on consents forms
Responsible: Clinical Supervisor
Date of completion: 11/20/22
2.Clinical Supervisor will provide a in-service training to all staff regarding the proper completion of consents and what triggers a need for a consents and purpose of the disclosure.
Responsible: Clinical Supervisor
Date of completion: 11/20/22
3.Clinical Supervisor will conduct random audits of three (3)charts per clinician each month to validate that staff members are correctly completing consent forms \
Responsible: Clinical Supervisor
Date of completion: 11/20/22
4.Clinical Supervisor will document outcome of consent audit in Performance Improvement report
Responsible: Clinical Supervisor
Date of completion: 11/20/22
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the decision to involuntarily terminate the client's treatment at the project, including the reason for termination, in one of one applicable client records reviewed.
Client # 13 was admitted to the inpatient non-hospital activity on March 8, 2022 and was administratively discharged on April 21, 2022. There was no documentation in the record indicating that the client was notified in writing of the facility's decision to involuntarily terminate the client's treatment at the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Supervisor will retrain the staff on the protocol in carrying out an Administrative Discharge i.e. notification of termination. All staff will receive the written policy and will sign the attendance sheet verifying that they were trained in the correct protocol.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
2. Clinical Supervisor will add Discharge Type and Intent to Discharge (If Applicable) to the chart review form that is given to the staff to monitor form completion. This form will be given to the Clinical Supervisor to review during monthly supervision.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
3.Clinical Supervisor will review all Administrative Discharges as they occur to ensure compliance.
a. Responsible party ?Clinical
Supervisor
Completion date 11/1/2022
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709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide an involuntarily terminated client with an opportunity to request reconsideration of the facility's decision to terminate treatment in one of one applicable client records reviewed.
Client # 13 was admitted to the inpatient non-hospital activity on March 8, 2022 and was administratively discharged on April 21, 2022. There was no documentation in the record indicating that the client was given the opportunity to request reconsideration of the facility's decision to terminate treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Clinical Supervisor will retrain the staff on the protocol in carrying out an Administrative Discharge i.e. giving client the opportunity to request reconsideration of the decision to terminate. All staff will receive the written policy and will sign the attendance sheet verifying that they were trained in the correct protocol.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
2. Clinical Supervisor will add Discharge Type and Intent to Discharge (If Applicable) to the chart review form that is given to the staff to monitor form completion. This form will be given to the Clinical Supervisor to review during monthly supervision.
a. Responsible party ?Clinical
supervisor
Completion date 11/1/2022
3 .Clinical Supervisor will review all Administrative Discharges as they occur to ensure compliance.
a. Responsible party ?Clinical
Supervisor
Completion date 11/1/2022
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