INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 3, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, LaRocco 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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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 shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information remained within the limits imposed by 4 Pa. Code 255.5 (b) in four of ten records reviewed.
The findings included:
4 Pa. Code 255.5 states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Ten client records were reviewed on December 3, 2014 for documentation of an informed and voluntary consent from the client that adhered to 4 Pa. Code 255.5. The facility failed to ensure that an informed and voluntary consent to release information remained within the limits imposed by 4 Pa. Code 255.5 (b) in client records #5,7,9 and 10.
Client #5 was admitted to treatment on August 11, 2014 and was still a client at the time of this inspection. The Consent and Authorization for the Release of Information to "Speciality Courts Assessment Team" signed and dated August 11, 2014 exceeded the parameters of 4 Pa. Code 255.5 by permitting the release of the following information: history and physical; discharge summary / aftercare plan; treatment progress reports; psychiatric evaluation; general progress update, MARS, and psychological assessment.
Client #7 was admitted to treatment on May 27, 2014 and was still a client at the time of this inspection. The Consent and Authorization for the Release of Information to "Speciality Courts Assessment Team" signed and dated May 27, 2014 exceeded the parameters of 4 Pa. Code 255.5 by permitting the release of the following information: history and physical; discharge summary / aftercare plan; treatment progress reports; psychiatric evaluation; general progress update, MARS, and psychological assessment.
Client #9 was admitted to treatment on August 7, 2014 and was still a client at the time of this inspection. The Consent and Authorization for the Release of Information to "Speciality Courts Assessment Team" signed and dated August 7, 2014 exceeded the parameters of 4 Pa. Code 255.5 by permitting the release of the following information: history and physical; discharge summary / aftercare plan; treatment progress reports; psychiatric evaluation; general progress update, MARS, and psychological assessment.
Client #10 was admitted to treatment on August 7, 2014 and was still a client at the time of this inspection. The Consent and Authorization for the Release of Information to "Speciality Courts Assessment Team" signed and dated August 7, 2014 exceeded the parameters of 4 Pa. Code 255.5 by permitting the release of the following information: history and physical; discharge summary / aftercare plan; treatment progress reports; psychiatric evaluation; general progress update, MARS, and psychological assessment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LaRocco Counseling INC has created and put into effect a new release for Specialty Court Assessment Team Clients which limits release of information to fit the guidelines of 4 Pa. Code 255.5 |
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 logs, the facility failed to maintain a written fire drill record that included 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.
The findings include:
Fire drill logs for the time period of June 2014 to October 2014 were reviewed. The fire drill logs that were documented did not include 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.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
LaRocco Counseling INC has modified the Fire Drill Log and to include 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. This log is currently in effect
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