INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 15, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Hispanic American Organization, 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) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on a review of the March 2023 through January 2024 fire drill logs, the facility failed to conduct fire drills during normal staffing conditions.
The log for the fire drill conducted on May 26, 2023 documented that the drill was conducted at 7:00AM, which is outside of the facility's hours of operation. The facility's hours of operation are Monday through Friday from 8:00AM to 8:30PM.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will conduct and document all fire drills during the facility's hours of operation on Monday through Friday from 8:00AM to 8:30PM. That are the hours of operations. |
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 the disclosure was to be made to on consent forms in three of seven client records reviewed.
Client #2 was admitted on January 9, 2024 and was active at the time of inspection. A release of information form was signed and dated by the client on January 9, 2024 and indicated the name of the person to whom disclosure would be made to as "PCP pending."
Client #6 was admitted on October 17, 2023 and was discharged on November 30. 2023. A release of information form to an emergency contact was signed and dated by the client on October 16, 2023 and did not include the name of the person to whom the disclosure was to be made.
Client #7 was admitted on October 24, 2023 and was discharged on December 28, 2023. A release of information form was signed and dated by the client on October 24, 2023 and indicated the name of the person to whom disclosure would be made to as "primary care provider."
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review all Assessments and Intakes Initial ROI to confirm completion of "primary care provider." with the name of provider in all releases of Information for PCI, that a disclosure could or would be made. All ROI file in clients records for emergency contact signed and dated by the client will include the name of the person to whom the disclosure will be to be made to.In the case the client refused to provide Emergency contact release of information a Note will be entered that will state. Ct refused all emergency contact.
The Clinical Supervisor will review all Release of informations with D&A team to provide information and guidance on full completion of ROI by 3/31/2024. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review client records, the facility failed to document the specific information to be disclosed on release of information forms in one of seven client records reviewed.
Client #6 was admitted on October 17, 2023 and was discharged on November 30, 2023. The release of information forms to a funding source and government agencies were signed and dated by the client on October 17, 2023, but none of the release forms included the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will review all new Releases of Information to make sure that release of information forms to a funding source and government agencies included the specific information to be disclosed.
The Director will provided a team review of completion of Releases of information to funding sources and governing fundings to ensure that are completed in all parts to be signed by clients.
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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 seven client records reviewed.
Client #2 was admitted on October 17, 2023. The release of information forms to a funding source and government agencies were signed and dated by the client on October 17, 2023, but none of the release forms included the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will conduct review starting on 3/15/2024 of all intake and assessments of all release of Information to ensure that all document the purpose of the disclosure.
In client #2 still active and the correction was complete on 3/15/2024 to include the purpose of the disclosure. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every sixty days in two of four applicable client records reviewed.
Client #3 was admitted on December 7, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was completed on December 11, 2023 and the first update was due no later than February 11, 2024; however, the update was not completed at the time of inspection.
Client #7 was admitted on October 24, 2023 and was discharged on December 28, 2023. The comprehensive treatment plan was completed October 24, 2022 and the first update was due no later than December 24, 2023; however, the update was not completed prior to discharge.
This is a repeat citation from the March 16, 2023 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical supervisor will review 100% of all active cases to ensure that updates are done are on or before every 60 day. The organization will implement a automatic schedule review within the Credible (EMR) to ensure that updates are completed at a timely manner.
The treatment plan update in the active client #3, file was completed on 3/15/2024,
EMR- Credible System will be implemented by March 31,2024 |