INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 13, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Treatment Access and Services Center of Berks County, 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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705.28 (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 the review of fire drill records, the facility failed to document unannounced fire drills were conducted at least once a month.
The findings included:
During the on-site renewal inspection, fire drill records were reviewed for January 2013 to December 2013. The facility failed to document unannounced fire drills for January 2013 to June 2013.
The facility director provided the fire drill record and confirmed the findings.
This is a repeat deficiency from the February 20, 2013 on-site inspection.
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Plan of Correction
Unannounced fire drills will be conducted onsite monthly and documented electronically in a file on the facility's shared drive. Facility Unit Mangers will be responsible for conducting fire drills on a rotating monthly basis. The Executive Director will oversee this procedure and ensure that fire drills are conducted each month. It is noted that drills were not documented from January 2013-June 2013, however the procedures mentioned above have been in place since July 2013 and fire drills will continue to be conducted in this manner. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings included:
During the on-site renewal inspection, fire drill records were reviewed for January 2013 to December 2013. The failed to document fire drills for January 2013 to June 2013. Additionally, the facility documented the use of the South Fire Exit stairs on the fire drills recorded for July 2013 to December 2013. An alternate exit route was not prepared.
The facility director provided the fire drill record and confirmed the findings.
This is a repeat deficiency from the February 20, 2013 on-site inspection.
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Plan of Correction
The facility will conduct unannounced fire drills monthly. Unit managers will be responsible for planning the dates, times and routes on a rotating monthly basis. Unit managers will check the log regarding routes recently used and ensure that alternative routes are taken on a regular basis; specifically the North Fire Exit stairs they are the identified alternate exit route. The executive director will oversee these procedures and check the log regularly to ensure that alternative routes are being used. |
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:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in one of six records. Additionally, the facility failed to maintain the confidentiality of client records in one of six records.
The findings included:
Six client records were reviewed during the on-site inspection. All records were reviewed for an informed and voluntary consent to release information. The facility failed to ensure a signed consent to release information contained all of the required elements in client record, # 6. In client record # 1, the facility failed to ensure the confidentiality of the client record.
Client record # 1 contained a consent form that was signed by another client.
Client record # 6 contained a consent to release information for a treatment provider. The consent failed to identify the provider to whom the disclosure would be made.
The findings were reviewed with the facility director who confirmed the findings.
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Plan of Correction
The facility will ensure that consent forms are completed, uploaded and attached accurately. The procedures for completing consents and capturing client signatures will be updated to include client validation of provider, expiration date and signature prior saving the document. The procudures for uploading documents will be updated to include previewing the document before uploading to ensure that the file is complete and the file is associated with the correct client. Previewing will be achieved via the "Preview Pane" feature in Windows. The facility director, intake supervisor, confidentiality compliance officer and IT consultant will conduct a staff training to review the procedure for completing consent forms electronically and uploading them into the STAR system. The purpose of this training will be to review the elements of a valid consent and review the revised consent completing and consent uploading procedures outlined above. The intake supervisor will audit at least 10 charts per week to ensure that all consents are complete and uploaded correctly. The intake supervisor will follow up with staff regarding the new procedures at monthly at staff meetings. The intake supervisor will report progress or problems to the facility director monthly or more as needed. |
709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
Based on the review of client records, the facility failed to document a consent to treatment form was completed and signed by the client upon intake in three of six records.
The findings included:
Six client records were reviewed during the on-site inspection. All records were reviewed for a consent to treatment signed by the client upon intake. The facility failed to document a signed consent to treatment in client records, #3, 4 and 5.
In client record # 3 an intake was documented on January 8, 2014. A consent to treatment had been signed by the client on January 24, 2013. A consent to treatment was not documented for the most recent intake at the time of the review.
In client record # 4 an intake was documented on January 8, 2014. A consent to treatment had been signed by the client on December 19, 2013. A consent to treatment was not documented for the most recent intake at the time of the review.
In client record # 5 an intake was documented on January 8, 2014. A consent to treatment had been signed by the client on November 27, 2012. A consent to treatment was not documented for the most recent intake at the time of the review.
The findings were reviewed with the facility director who confirmed the findings.
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Plan of Correction
The facility will ensure that clients review and sign a consent to treatment form upon every screen or assessment event. The facility director and intake supervisor will conduct a staff training to review the elements and purpose of a consent to treatment form. Staff will also be instructed that the form must be completed at every screening or assessment for every client. The intake supervisor will audit at least 10 charts per week to ensure that a consent to treatment has been completed for every client screen or assessment. The intake supervisor will follow up with staff regarding this new procedure monthly at staff meetings. The intake supervisor will report progress or problems to the facility director monthly or more as needed. |