INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 11-12, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Public Health Management Corporation/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
Based on a review of 5 personnel records, the facility failed to conduct fire extinguisher training upon employment in 1 record reviewed.
Employee #5 was hired on 5/22/17 and was still employed. Fire extinguisher training was not documented until 9/19/17.
This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
Employee trainings for fire extinguishers will be included as part of the new hire process and will be incorporated in the initial orientation of new hire staff within the first three days of employment.
This will be monitored by HR and the Program Director. |
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.
|
Observations
Based on the review of the fire drill logs for October 2016 through August 2017, the facility failed to prepare alternate exit routes to be used during fire drills. The Callowhill St. ramp was the exit route used during every fire drill that took place during that time period.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective immediately during fire drills participants in the program will exercise utilizing alternate exits in order to be familiar with all available exits in the case of a fire or other emergency.
The Administrative Asst. will conduct monthly fire drills where staff will lead participants to nearest exit also including the 12th street exit from the program.
The Program Director will ensure and monitor that this practice is implemented on a monthly basis. |
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
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 1 of 11 client records. Additionally, 5 of 11 client records had consent to release forms that were missing elements.
Client #2 was admitted into the outpatient level of care on 5/18/17 and was an active client at the time of the inspection. There was a consent form to a primary care physician; however, it did not include the purpose for disclosure, or dated client and witness signatures.
Client #3 was admitted into the outpatient level of care on 3/30/16 and still an active client at the time of the inspection. There was documentation that the facility was billing the funding source; however, the last consent to the funding source expired 3/30/17. No updated form was on file.
Client #5 was admitted into the outpatient level of care on 1/27/17 and was discharged on 8/25/17. There was a consent form to a family member signed and dated on 1/27/17; however, it did not indicate the information to be released. Additionally, there was a consent to an organization signed and dated on 01/27/17; however, it listed "other" for the purpose, but did not specify the purpose for the disclosure.
Client #7 was admitted into the outpatient level of care on 1/31/17 and was discharged on 4/4/17. There was a consent form signed and dated on 01/31/17; however, it did not include a specific name, agency or organization to whom disclosure was being made. Additionally, there was another consent form signed on 1/31/17; however, it did not include a specific name, agency or organization to whom disclosure was being made, or the purpose for the disclosure.
Client #8 was admitted into the intake, evaluation and referral activity on 2/6/17. There was a consent form to a probation officer signed and dated on 2/7/17; however, it did not include the purpose for disclosure.
Client #11 was admitted into the intake, evaluation and referral activity on 5/18/17. There was a consent form to a primary care physician; however, it did not include the purpose for disclosure, or a dated client and witness signature.
The findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Clinical staff, including Admissions Coor. will receive training on required elements on the Authorizations to Release information per 709 Confidentiality regulations. Training will be conducted by the Program Director. Staff will complete the training by 12 . Upon completion of the training, therapists will review authorizations to release information for all currently assigned active caseloads, including client #2 and #3. Upon completion of the review, therapists will make corrections and have active clients sign new releases for those which contained errors and missing information. This will be completed and reported to the Program Director by 12/11/2017. This will include intake and when participants level of care changes.
This will be monitored by the Clinical Director and Program Director. |
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
Based on a review of 11 client records, every record lacked documentation verifying written acknowledgement by the client that they had been notified of some of their client rights, including that facility staff may limit access to their records if determined to be detrimental, the right to appeal a decision limiting access to their records, the reasons for such limitations are to be documented in the record, and the right to request the correction of inaccurate information in the record.
These findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
During Intake process Participant will sign a client rights release form stating the limitations of record access, right to appeal a decision limiting access, reasons for such limitations are to be documented and the rights to request correction of inaccurate information in the record.
All current participants will be given a Participants Rights document to sign acknowledging that they have been informed of their rights regarding the client record access and rights regarding the client record limitations.
This will be conducted by the Admissions Coor. and monitored by the Clinical and Program Director as well as Total Quality Management. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
|
Observations
Based on the review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days following the unusual incidents below, which were discovered during the licensing process.
The incident dates and incident reasons are:
June 23, 2017 - Client death
July 20, 1027 - Police presence requested
These findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
Moving forward all staff will be informed and expected to complete incident reports and notify DDAP within 3 business days regarding incidents where police presence, death or disaster has occurred.
As of 11/09/2017 the 2 incidents noted in the citation were faxed to DDAP at 717-787-3188.
This will be monitored by Program Director as well as Total Quality Management. |