INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 14, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addictions Treatment 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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705.28 (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.
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Observations
Based on a review of fire drill records, the facility failed to document monthly fire drills from April 2020 through March 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall ensure monthly fire drills resume at vacated satellite sites on a monthly basis starting April 2021. Assigned clinician will drive to physical location monthly in order to conduct monthly fire drill. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personnel records, the facility failed to document an annual performance evaluation in one of two records reviewed on April 14, 2020.
Employee # 1 was hired on August 29, 2018. No annual performance evaluations were documented in employee record # 1.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director shall ensure all performance evaluations are conducted on a yearly basis. Facility Director will conduct current employee annual evaluations of clinicians in February 2022, June 2021, and December 2021. Executive Director will complete Facility Director evaluation in August 2021. |
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
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in two of four records reviewed on April 14, 2021.
Client # 3 was admitted March 18, 2020. A treatment progress update was faxed to probation on April 8, 2021 without the client ' s written consent.
Client # 4 was admitted April 13, 2016. Treatment progress updates were faxed to a treatment provider on March 2, 2021 and April 8, 2021 without the client ' s written consent.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Agency shall review all currently active patient charts and obtain written consent for these charts. Checks shall be tracked on newly updated Consent Summary Spreadsheet. Facility Director shall ensure all future first patient appointments by clinician occur physically on grounds. Prior to meeting with clinician, perspective patient will engage in registration process with support staff as written consent/releases of information are facilitated in this process. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility did document a consent to release information form but failed to include the dated signature of the client in three of four records reviewed on April 14, 2021.
Client # 2 was admitted February 19, 2020 and discharged March 24, 2021. Consents documented on February 4, 2021 for a physician, emergency contact and insurance company did not include the dated signature of the client.
Client # 3 was admitted March 18, 2020. A consent documented on February 24, 2021 for a treatment provider did not include a dated signature of the client. Consents documented on March 3, 2021 for a physician, probation and insurance company did not include the dated signature of the client.
Client # 4 was admitted April 13, 2016. Consents documented on January 27, 2021 for a treatment provider, emergency contact and insurance company did not include the dated signature of the client.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Agency shall review all currently active patient charts and obtain written consent for these active charts. Agency shall utilize process of visual inspection of consents at time of facilitation to ensure consents are both signed and dated. In the event a paper release of information needs to be uploaded to the electronic medical record this documentation will be visually inspected and will not be uploaded until the client manually signs and manually dates paper (non-electronic) release of information. No correspondence will be sent to outside providers / entities until written consent has been obtained. |