INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring inspection conducted on February 22 - 23, 2021 staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center 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) (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 a review of the facility's February 2019 - January 2021 fire drill records, the facility failed to document the use of alternate exit routes.
Both the front and back exits were used for every fire drill.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill log was reviewed and updated to include a an area to document the amount of individuals who utilized the alternate exit routes. The updated documentation will be reviewed with front desk and administrative staff individually by 4/1/2021 to ensure compliance with this regulation. In order to ensure future compliance the facility director will review the fire drills quarterly to ensure that the same exit is not being utilized for every fire drill. |
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
Based on a review of the facility's annual reports, the facility failed to provide documentation the January - December 2019 annual report was made available to the public.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The annual report for 2019 will be made available to the public utilizing local advertising with the annual report for 2020 on or before 5/1/2021. The facility director will be responsible to ensure that all future annual reports are made available to the public each year as required. |
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 of client records, the specific information documented on the consent to release information form exceeded the limitations imposed at 4 Pa. Code 255.5 in six of eight client records reviewed on February 22 - 23, 2021.
The consents for the funding entity and a government agency in the following records indicated the specific information to be released included: financial information, audit compliance documents and compliance resolution documents.
Client # 3 was admitted April 5, 2017 and discharged September 16, 2020. Consents for the funding entity and a government agency were documented February 12, 2019.
Client # 4 was admitted August 15, 2019 and discharged October 8, 2020. Consents for the funding entity and a government agency were documented August 15, 2019.
Client # 5 was admitted August 12, 2006 and discharged November 28, 2020. Consents for the funding entity and a government agency were documented March 13, 2019.
Client # 6 was admitted March 18, 2020. Consents for the funding entity and a government agency were documented March 18, 2020.
Client # 7 was admitted June 24, 2020. Consents for the funding entity were documented June 24, 2020.
Client # 8 was admitted June 5, 2014. Consents for the funding entity and a government agency were documented February 10, 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RHJ has a standardized release of information for the funding and government entities. The form was updated to include only items that did not exceed 4 Pa. Code 255.5. Both the form and the Pa Code were reviewed with staff 3/3/2021 and staff were instructed to review the updated release with all clients who receive funding and to request that the updated release of information be signed. The updated release of information will then be placed in the clinical record. The clinical supervisor will perform random chart audits and review releases of information to ensure future compliance with 255.5. |