INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 31, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Public Health Management Corporation d/b/a Chances 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:
|
Plan of Correction
|
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Five personnel records were reviewed on October 31, 2018. Three of these personnel records were reviewed for the documentation of fire extinguisher training. For employee record # 4, the facility failed to document the completion of fire extinguisher training within the first 7 days following the date of hire.
Employee # 4 was hired as a counselor on September 4, 2018. The employee's record did not contain documentation of completed fire extinguisher training. Facility staff confirmed that this training was not provided to the employee, as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Staff will be instructed in the use of the fire extinguisher at their initial on-site orientation to the program conducted by their immediate supervisor, which will occur within 7 days from their date of hire. Employee #4 who had not received the fire extinguisher training has received it as of 11/21/2018 CHANCES Fire Safety Policy and procedure will be updated with language that shows the requirement for supervisors to conduct and document this training within 7 days from their date of hire. Initial on-site staff orientation checklist form will be updated to include fire extinguisher training within 7 days following the date of hire. Supervisors will review training completion for existing employees during supervision. Any existing employees without documentation of fire extinguisher use training will be instructed by their supervisors, and documentation of training completion will be entered into the training log and official PHMC HR record. Project Director will ensure that that the revised policy and procedure is followed for new hires via regular review of new hire documentation prior to submission into the training log and submission into the official PHMC HR Record. Regular (quarterly) Quality Reviews by PHMC's Quality Management Department will include review of training logs to ensure that training and documentation has been completed. |
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.
|
Observations
The facility's fire drill records were reviewed on October 31, 2018, for the time period of November 2017 - September 2018. On the record of a fire drill conducted on November 13, 2017, the facility failed to document the time of the fire drill. On the same fire drill log, the facility also failed to fully document the amount of time it took for the evacuation.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Project Director will conduct a staff training reinforcing the 705.28 Fire safety fire drill requirements and CHANCES Fire Safety fire drill Policy and Procedures. Staff instruction will include conducting fire drills and completing documentation of fire drills Training will be conducted and documented for all staff by the Project Director. Regular (quarterly) Quality Reviews by PHMC's Quality Management Department will include review of fire drill logs to ensure that documentation is complete |
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.
|
Observations
Ten client records were reviewed on October 31, 2018. The facility failed to obtain an applicable informed and voluntary consent to release information for client records # 2 and 4.
Client # 2 was admitted into treatment on February 13, 2018 and was still active in treatment. The client's record contained documentation of a fax that was sent to a pharmacy on May 14, 2018, regarding the client's medical prescriptions. A consent to release information to this pharmacy was not documented in the client's record.
Client # 4 was admitted into treatment on May 9, 2018 and was discharged on August 28, 2018. The client's record contained documentation of a fax that was sent to a human services agency on June 20, 2018, regarding the client's presence in treatment at the facility. A consent to release information to that agency was not documented in the client's record.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Clinical Director will conduct a staff training reinforcing the 709.28 Confidentiality requirements and CHANCES 709.28 Confidentiality Policy and Procedures. Staff instruction will include policy and procedures on the requirements and use and proper documentation of Consents to Release Information prior to the information's release. Training will be conducted and documented for all staff by the Clinical Director. Regular (quarterly) Quality Reviews by PHMC's Quality Management Department will include review of participant chart files to ensure that information released included proper consents |
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.
|
Observations
Ten client records were reviewed on October 31, 2018. For client records # 7, 8, 9, and 10, the facility failed to document written acknowledgement that the client had been fully informed of their client rights.
Client # 7 received an evaluation for treatment services through the facility ' s Intake, Evaluation, and Referral activity on June 18, 2018.
Client # 8 received an evaluation for treatment services through the facility ' s Intake, Evaluation, and Referral activity on August 3, 2018.
Client # 9 received an evaluation for treatment services through the facility ' s Intake, Evaluation, and Referral activity on August 3, 2018.
Client # 10 received an evaluation for treatment services through the facility ' s Intake, Evaluation, and Referral activity on July 27, 2018.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation. The facility was cited for non-compliance of this regulation during the previous licensing inspection, conducted on October 11-12, 2017.
|
Plan of Correction
CHANCES 709.30 Client Rights Policy and Procedure will be revised for staff to document written acknowledgement by clients who are participating in Intake, Evaluation, and Referral Activity that they have been notified of their Client Rights. Client Rights Forms will be revised and put into use by Intake, Evaluation, and Referral Activity staff to use for clients participating in Intake, Evaluation, and Referral Activity. Policies and procedures will be updated so that staff document notification of client rights and enter it into the client record upon admission into CHANCES Intake, Evaluation, and Referral Activity. Staff who are conducting Intake, Evaluation, and Referral Activity will be instructed in the revised CHANCES 709.30 Client Rights Policy and Procedure and instructed in the use and completion of the Clients Rights Form by the Project Director. Regular (quarterly) Quality Reviews by PHMC's Quality Management Department will include review of participant chart files to ensure that documentation of notification of Client Rights was completed according to CHANCES revised 709.30 Client Rights Policy and Procedure. |
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.
|
Observations
Four client records were reviewed for the intake, evaluation, and referral activity on October 31, 2018. The facility failed to document a facility consent to treatment form for client records # 7, 8, 9, and 10.
Client # 7 received an evaluation for treatment services on June 18, 2018.
Client # 8 received an evaluation for treatment services on August 3, 2018.
Client # 9 received an evaluation for treatment services on August 3, 2018.
Client # 10 received an evaluation for treatment services on July 27, 2018.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
CHANCES Informed Consent Policy and Procedure will be revised for a consent to treatment form to be completed and signed by the client and intake worker at intake for clients who are participating in Intake, Evaluation, and Referral Activity. Client Informed Consent to Treatment Forms will be revised and put into use by Intake, Evaluation, and Referral Activity intake staff to use for clients participating in Intake, Evaluation, and Referral Activity. Staff who are conducting Intake, Evaluation, and Referral Activity intakes will be instructed in the revised CHANCES Informed Consent Policy and Procedure and instructed in the use and completion of the Informed Consent to Treatment Form by the Project Director. Regular (quarterly) Quality Reviews by PHMC's Quality Management Department will include review of participant chart files to ensure that documentation of Informed Consent to Treatment was completed according to CHANCES revised Informed Consent Policy and Procedure. |