INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 30, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Spanish American Civic Association for Equality, inc. 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill logs from April 2020 until March 2021, the facility failed to conduct a sleeping hours fire drill at least every 6 months. A sleeping hours fire drill was conduct on August 16, 2020. Another sleeping hours fire drill was due by February 2021; however no sleeping hour fire drill was conducting by the time of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Overnight sleeping fire drill completed on 4/11/2021 and fire drill schedule re-written to include overnight drills twice for 2021, and twice for every year following with the operation manager as the responsible party to hold and document this even |
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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client records, #3 and #7.
Client #3 was admitted on December 3, 2020 and was still an active client at the time of the inspection. There was documentation that a fax was sent to the local judge on March 22, 2021; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #7 was admitted on June 29, 2020 and was discharged on November 9, 2020. There was documentation that a fax was sent to the local judge on July 16, 2020; however, there was no proper consent to release information form signed by the client prior to disclosure.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Client #3 was asked to complete consents and reason why they would be needed which he did. The director retrained the intake person to ensure compliance. operations manager will ensure compliance with weekly audits of new intakes for the next 6 months then random audits going forward. |
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 seven client records, the facility failed to ensure that all consents to release information contained the name of the person, agency or organization to whom the disclosure is made in client record#1.
Client #1 was admitted on December 9, 2020 and was still active at the time of the inspection. A consent to release form was signed and dated on December 9, 2020 that failed to include the name of the person, agency, or organization.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Intake worker retrained on consent to release information by director. Client #1 was informed of the need to sign a consent if information was to be released. He completed release. Intake paperwork to be audited weekly for all new clients going forward by operations manager. the operations manager will ensure actions are implemented through audits and continuously offer trainings on paperwork to staff, |
709.32 (c) (2) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
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Observations
Based on a discussion with facility staff and a physical plant inspection, the facility failed to ensure that all controlled substances were securely stored in accordance to State and Federal regulations and program standards as the controlled substances were not double locked as the medication was kept in a medication cabinet in a common area.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
On April 1, 2021 a lock box was purchased and all controlled substance were placed in the lock box in a locked cabinet. All staff were retrained on the process. Operations manager will ensure compliance going forward. Random check of cabinet will be competed by director |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of client medical records, the facility failed to ensure that missed medication was documented in the medical records in all five applicable client records
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Staff were retrained on the process of documenting medication record, errors in the record and reason why there is non-adherence if it occurs. Counselor will follow up with non-adherence as documented. Operations manager will audits medication chart weekly and alert director to any deviation from policy |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on review of seven client records, the facility failed to ensure that records included documentation of a physical examination in five client records.
Client #1 was admitted on December 9, 2020 and was still active at the time of the inspection.
Client #2 was admitted on December 4, 2020 and was still active at the time of the inspection
Client #3 was admitted on December 3, 2020 and was still active at the time of the inspection
Client #4 was admitted on December 9, 2020 and was still active at the time of the inspection
Client #5 was admitted on November 4, 2020 and was discharged on March 4, 2021.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Physical were requested on all 5 clients from referring treatment facilities and placed in charts. All future referrals must contain a physical as part of the referral process going forward. Operations manger will ensure during referral process that this information is obtained. Director will complete random audits bi-monthly to ensure this process is followed. |