INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 13, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Human Services Administration 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) (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
During the administrative review for the annual inspection on March 13, 2019, the facility failed to document monthly fire drills.
Fire drill reports were reviewed from March 2018 to February 2019, and fire drills were not documented for April 2018, June 2018, July 2018, August 2018, September 2018, October 2018, December 2018, January 2019, and February 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drills will be executed on a monthly basis unless otherwise indicated by DDAP.
Compliance with this expectation will be monitored by the Project Director and/or the Facility Director.
Facility to be in full compliance with these standards by 3/21/2019.
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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
The facility failed to document the exit routes used and the problems encountered during fire drills.
Fire drill records for the period of March 2018 to February 2019 were reviewed on March 13, 2019. Only two fire drill records, May 2018 and November 2018, were documented during the time frame. Both failed to document the exit route used and the problems encountered.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Appropriate documentation will be completed at the time of each fire drill. This is to include the exit routes utilized and any problems encountered during the drill.
Compliance with this expectation will be monitored by the Project Director and/or the Facility Director.
Facility to be in full compliance with these standards by 3/21/2019.
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709.22 (b) (1) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(1) Designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly.
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Observations
During the administrative review for the annual inspection on March 13, 2019, the facility failed to document the designation of the project director position by the governing body.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Human Services Administration Organization will have documentation that designates the Executive Director as the Project Director. This will be signed off on by the governing body.
Compliance with expectation will be monitored by the Project Director and/or the Facility Director.
Facility to be in full compliance with these standards by 3/21/19.
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709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) 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, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
During the administrative review for the annual inspection on March 13, 2019, the facility failed to make the annual report available to the public and to include a statement disclosing the names of officers, directors and principal shareholder.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On an annual basis this facility shall make a report available to the public that includes information regarding the names of officers, directors, and principle shareholders.
Compliance with expectation will be monitored by the Project Director and/or the Facility Director.
Facility to be in full compliance with these standards by 3/21/19.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
During the administrative review for the annual inspection on March 13, 2019, the facility failed to document by written signature that the project director prepared, and annually updated the policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On an annual basis this facility will document that all policies and procedures have been reviewed, and when appropriate, updated. After review, the Project Director will indicate this by way of their written signature.
Compliance with expectation will be monitored by the Project Director.
Facility to be in full compliance with these standards by 3/21/19.
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709.24 (a) (1) MEMO Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(1) Definition of the target population toward whom facility services are directed.
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Observations
During the administrative review for the annual inspection on March 13, 2019, the facility failed to document the governing body adopted the written plan for client services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The written plan for treatment and rehabilitation management shall be adopted by the governing body. This will occur by way of a signed acknowledgement.
Compliance with this expectation will be monitored by the Project Director and/or the Facility Director.
Facility to be in full compliance with these standards by 3/21/19.
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709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
During the administrative review for the annual inspection on March 13, 2019, the facility failed to document the governing body adopted the written personnel policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The written plan for personnel management that follows state and federal employment laws shall be adopted by the governing body. This will occur by way of a signed acknowledgement.
Compliance with this expectation will be monitored by the Project Director and/or the Facility Director.
Facility to be in full compliance with these standards by 3/21/19.
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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
The facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Six client records were reviewed on March 13, 2019. Client record #2 contained a letter dated 2-1-2019 to an outside agency , but there was not a signed consent to release information to the outside agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As part of ongoing quality assurance measures a process will be implemented whereby all obtained consents are reviewed by the IMPACT Supervisor to ensure best practices around confidentiality. Consents will continue to be completed at the time of assessment and can be updated as needed.
The implementation of this process will be introduced to staff and ongoing oversight to ensure compliance will be monitored by the IMPACT Supervisor.
Facility to be in full compliance by 3/21/2019.
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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
The facility failed to document the person, agency or organization to whom the information will be disclosed on the signed consents to release information in client record # 3.
Six client records were reviewed on March 13, 2019. Client record #3 included a release of information form signed on July 17, 2018 that did not include the person, agency or organization to whom the information will be disclosed
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As part of ongoing quality assurance measures a process will be implemented whereby all obtained consents are reviewed by the IMPACT Supervisor to ensure best practices around confidentiality. Consents will continue to be completed at the time of assessment and can be updated as needed.
The implementation of this process will be introduced to staff and ongoing oversight to ensure compliance will be monitored by the IMPACT Supervisor.
Facility to be in full compliance by 3/21/2019.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written acknowledgement by clients that they have been notified of their rights in six of six client records reviewed on March 13, 2019.
Six client records were reviewed, and six client records did not include the documentation.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
As part of the intake process all clients will be oriented to their rights by way of reviewing the consumer bill of rights document that the assessor will provide. After reviewing this documentation individuals will be asked to sign an acknowledgement form that will then become part of their client record.
The use of this form will be reviewed with staff ongoing oversight to ensure compliance will be monitored by the IMPACT Supervisor.
Facility to be in full compliance by 3/21/2019.
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