INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20 - 21, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, Inc. / Vandergrift LLC 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a fire drill record that included the amount of time it took for evacuation and the problems encountered.
The findings include:
Fire drill records were reviewed on March 20, 2013. The facility failed to document the amount of time it took for evacuation during the following drills: March 2012, June 2012, July 2012, August 2012, October 2012, November 2012, January 2013 and February 2013. The facility failed to document the problems encountered from March 2012 through February 2013.
The project/facility director and clinical supervisor were interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The front desk manager is responsible to ensure compliance with this standard. In order to obtain and maintain compliance with this standard the fire drill form will be revised by the project director to more clearly document the amount of time it took for evacuation and the problems encountered during the evacuation. The front desk manager as well as the front desk staff will then be trained on the updated form. The front desk manager will then inspect the new form for completion monthly to ensure proper documentation. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the 2011 annual report and administrative documentation, the governing body failed to make the 2011 annual report available to the public.
The findings include:
The annual report for January 1 through December 31, 2011 was reviewed on March 20, 2013. The facility is publicly funded and the governing body is required to make the annual report available to the public. There was no documentation that the 2011 annual report was made available to the public, as of March 20, 2013.
The Project/Facility Director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The project director is responsible to ensure publication and maintain documentation of the publication of the availability of the annual report to the public. In order to maintain compliance with this standard a folder will be created that will be maintained by the project director to include a copy of the public notification that the annual report may be obtained, which will be made available to the department upon inspection. Due to the noncompliance for 2011 the facility will, upon completion of the 2012 annual report, publish the availability of the report to the public for both 2011 and 2012. A copy of the publication will be placed in the folder for inspection. Also reminders will be set annually to ensure that the facility is compliant with this standard. |
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 a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in eight of eight client records.
The findings include:
Sixteen client records were reviewed on March 20 - 21, 2013. Eight client records were reviewed for informed and voluntary written consents from the client. 42 CFR Part 2, Subpart C, subsection 2.31 (a)(8), requires a statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it. The consent can be revoked by the client verbally or in writing. The facility's consents to release information include the following statement: "I understand that I may revoke this consent at any time, it must be in writing". This is in violation of federal confidentiality regulations. The facility failed to obtain an informed and voluntary consent to release information from the client in client records # 1, 2, 3, 4, 5, 6, 7, 8.
The Project/Facility Director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The project director is responsible to ensure compliance with this standard. In order to become and maintain compliance the project director will revise the statement on all of the facility releases of information to include the statement that the releases may be revoked verbally or in writing at any time. All old releases releases will be replaced with the new releases. The project director will meet with staff to inform them of this change so that they replace all copies with the new document/ |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that included long term goals for treatment in five of eight clients records.
The findings include:
Sixteen client records were reviewed on March 20 - 21, 2013. Eight client records were reviewed for treatment plans that included long term treatment goals. The facility failed to document long term treatment goals in client records # 2, 3, 5, 7 and 8.
Client # 2 was admitted into treatment on September 19, 2012. The treatment plan for client # 2 was completed on October 12, 2012. The treatment plan did not include long term treatment goals.
Client # 3 was admitted into treatment on August 9, 2012. The treatment plan for client # 3 was completed on September 4, 2012. The treatment plan did not include long term treatment goals.
Client # 5 was admitted into treatment on October 9, 2012. The treatment plan for client # 5 was completed on November 5, 2012. The treatment plan did not include long term treatment goals.
Client # 7 was admitted into treatment on August 24, 2012. The treatment plan for client # 7 was completed on September 21, 2012. The treatment plan did not include long term treatment goals.
Client # 8 was admitted into treatment on September 7, 2012. The treatment plan for client # 8 was completed on October 4, 2012. The treatment plan did not include long term treatment goals.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The project director is responsible to ensure compliance with this regulation. In order to achieve and maintain compliance the treatment plan will be revised to include a long term treatment plan goal. This new treatment plan will then replace the previous treatment plan. The project director will meet wiht the clinical staff to provide the revised document and make them aware that this will replace the previous document. |