INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 31, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Laure Rohrs Gargano 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
Based on a review of administrative documentation and an interview with the facility director, the facility failed to conduct unannounced fire drills at least once per month in eight of eight months reviewed.
The findings include:
The facility director was asked to provide the fire drill logs on July 31, 2013. The facility became licensed on November 27, 2012. There was no documentation of unannounced fire drills for the months of November 2012, December 2012, January 2013, February 2013, March 2013, April 2013, May 2013, June 2013 and July 2013.
An interview took place with the facility director on July 31, 2013. It was confirmed that fire drills were not documented during those months.
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Plan of Correction
The facility director will schedule random monthly fire drills during hours of operation. An electronic calendar will create a reminder the first business day of each month to execute a fire drill. The facility director will select a date/time for the drill within the same month. The facility director will execute the drill, document the drill on the fire drill log and store the log in a binder available for review. |
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
Based on an interview with the facility director, the facility failed to document fire drills during normal staffing conditions.
The findings include:
The facility director was asked to provide the fire drill logs on July 31, 2013. The facility became licensed on November 27, 2012. There was no documentation of unannounced fire drills for the months of November 2012, December 2012, January 2013, February 2013, March 2013, April 2013, May 2013, June 2013 and July 2013.
An interview with the facility director on July 31, 2013 confirmed that the facility did not document fire drills during the eight month period.
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Plan of Correction
The facility director will create and implement a spreadsheet to document random fire drills during hours of operation. This form will include the following information:
date and time of the fire drill, number of staff; number of clients evacuated; length of time the evacuation took to complete; specify what exit was utilized; note if any problems were identified and what alarm was activated. The log will be kept in a binder for review. The facility director will be responsible to complete the fire drills, document the fire drill in the log, and address any identified problems. |
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 an interview with the facility director, the facility failed to 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.
The findings include:
Fire drill logs for the time period of November 2012- July 2013 were requested on July 31, 2013. The facility director confirmed that there were no records of facility fire drills documenting 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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Plan of Correction
The facility director will create and implement a spreadsheet to document random fire drills during hours of operation. This form will include the following information:
date and time of the fire drill, number of staff; number of clients evacuated; length of time the evacuation took to complete; specify what exit was utilized; note if any problems were identified and what alarm was activated. The log will be kept in a binder for review. The facility director will be responsible to complete the fire drills monthly, and document their outcome in the log monthly. The log will be kept in a binder for review. |
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 an interview with the facility director, the facility failed to document fire drills indicating the use of alternate exits.
The findings include:
The facility director was asked to provide the fire drill logs on July 31, 2013. The facility became licensed on November 27, 2012. There was no documentation of unannounced fire drills for the months of November 2012, December 2012, January 2013, February 2013, March 2013, April 2013, May 2013, June 2013 and July 2013.
An interview with the facility director on July 31, 2013 confirmed that the facility did not document fire drills during the eight month period.
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Plan of Correction
The facility director will create and implement a spreadsheet to document random fire drills during hours of operation. This form will include the following information:
date and time of the fire drill, number of staff; number of clients evacuated; length of time the evacuation took to complete; specify what exit was utilized; note if any problems were identified and what alarm was activated. The log will be kept in a binder for review. The facility director will be responsible to complete the fire drills monthly, and document their outcome in the log monthly. The log will be kept in a binder for review. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on an interview with the facility director, the facility failed to document fire drills during normal staffing conditions.
The findings include:
The facility director was asked to provide the fire drill logs on July 31, 2013. The facility became licensed on November 27, 2012. There was no documentation of unannounced fire drills for the months of November 2012, December 2012, January 2013, February 2013, March 2013, April 2013, May 2013, June 2013 and July 2013.
An interview with the facility director on July 31, 2013 confirmed that the facility did not document fire drills during the eight month period.
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Plan of Correction
The facility director will create and implement a spreadsheet to document random fire drills during hours of operation. This form will include the following information:
date and time of the fire drill, number of staff; number of clients evacuated; length of time the evacuation took to complete; specify what exit was utilized; note if any problems were identified and what alarm was activated. The log will be kept in a binder for review. The facility director will be responsible to complete the fire drills monthly, and document their outcome in the log monthly. The log will be kept in a binder for review. |
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. The consent shall be in writing and include, but not be limited to:
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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 was within the limits imposed by 4 Pa. Code 255.5 (b) in five of eight records reviewed.
The findings included:
4 Pa. Code 255.5 (b) states:
(b) Restrictions. Information released to judges, probation or parole officers,
insurance company health or hospital plan or governmental officials, under subsection
(a)(1), (2), (4), (7) and (8), 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) The prognosis of the client.
(3) The nature of the project.
(4) A brief description of the progress of the client.
(5) A short statement as to whether the client has relapsed into drug, or
alcohol abuse and the frequency of such relapse.
Eight client records were reviewed July 31, 2013. All records were reviewed regarding documentation for release of information. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in client records # 2, 3, 4, 5 and 7.
A review of client record # 2 revealed a consent to release for the probation officer dated 2/13/2013 that allowed for the release of the psychosocial/diagnostic summary, treatment plan and treatment plan updates, case consultations, discharge summary and medication records. The information permitted to be disclosed exceeded the limitations imposed by Pa Code 255.5 (b).
A review of client record # 3 revealed a consent to release for the probation officer dated 3/16/2013 that allowed for the release of the psychosocial/diagnostic summary, treatment plan updates, continuing care plan, case consultations and discharge summary. The information permitted to be disclosed exceeded the limitations imposed by Pa Code 255.5 (b).
A review of client record # 4 revealed a consent to release for the probation officer dated 3/3/2013 that allowed for the release of the psychosocial/diagnostic summary, treatment plan updates, continuing care plan, case consultations and discharge summary. The information permitted to be disclosed exceeded the limitations imposed by Pa Code 255.5 (b).
A review of client record # 5 revealed a consent to release for the probation officer dated 7/10/2013 that allowed for the release of the psychosocial/diagnostic summary, treatment plan updates, continuing care plan, case consultations, medication list, medical history, physical exam, nursing assessment, PPD results, and discharge summary. The information permitted to be disclosed exceeded the limitations imposed by Pa Code 255.5 (b).
A review of client record # 7 revealed a consent to release for the probation officer dated 6/29/2013 that allowed for the release of the psychosocial/diagnostic summary, treatment plan updates, continuing care plan, case consultations, medication list, medical history, physical exam, nursing assessment, PPD results and discharge summary. The information permitted to be disclosed exceeded the limitations imposed by Pa Code 255.5 (b).
The findings were confirmed with the facility director on July 31, 2013 and were not disputed.
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Plan of Correction
The facility director will create and implement two ROI's. One ROI will be limited to the 5 areas permitted for release under 4 PA Code 255.5 section (b). One ROI will allow for expanded release of information medical/behavioral health providers. The facility director will be responsible for training staff in utilization of the new consents. The facility director will be responsible to complete chart audits to assure compliance with the policy. |
709.31(a) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(a) If a project utilizes Department funds, it shall comply with the Department's UDCS.
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Observations
Based on the review of record documentation, the facility failed to comply with the Department's Uniform Data Collection System when the project utilized Department funds.
The findings included:
Eight client records were reviewed on July 31, 2013. All patients were funded by the Single County Authority which utilized Department Funds. The facility director was interviewed and she confirmed that she did not utilize the Department's Strengthening Treatment and Recovery data collection system.
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Plan of Correction
The facility director will attend STAR training on August 28 and 29th, 2013. The facility director will be responsible to implement the STAR program at the agency. The facility director will be responsible to train staff in the utilization of the STAR program. The facility director will be responsible to complete monthly review of STAR to assure all clients in service at the agency are accurately entered into the STAR system.
Once training and implementation have been completed; the facility director will be responsible to retroactively enter all drug and alcohol clients into the STAR system. This will be completed by October 31st 2013. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of seven client records.
The findings include:
Eight client records were reviewed on July 31, 2013. Seven client records records were required to include the type and frequency of treatment and rehabilitation services. The individual treatment and rehabilitation plans contained in client records #2, 6, and 8 did not include the type and frequency of treatment and rehabilitation services.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
The facility director will add a section to the treatment plans to specify: Long and short term goals; type and frequency of services recommended; specific community resource involvement, frequency recommended.The facility director will be responsible to train staff in utilization of the new treatment plan format. The facility director will be responsible to complete monthly chart audits to assure compliance with the policy. The facility director will utilize the agency electronic medical record to complete the charting audits. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client record, the facility failed to document an aftercare plan in two of two client records.
The findings include:
Eight client records were reviewed on July 31, 2013. Three records reviewed were discharged clients and two required aftercare plans. Per the facility policy, the counselor and client will complete an aftercare plan at the time of discharge for successful completions. The facility did not document an aftercare plan in client record # 2 and 3.
Client #2 was admitted on February 13, 2013 and successfully completed treatment on May 25, 2013. There was no documentation of an aftercare plan in the client record.
Client # 3 was admitted on March 16, 2013 and successfully completed treatment on June 29, 2013. There was no documentation of an aftercare plan in the client record.
This was discussed and confirmed with the facility director on July 31, 2013.
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Plan of Correction
The facility director will create and implement a form to outline after care recommendations and client goals prior to clients completion of treatment. This form will document: date of completion, client future goals with a time frame for achievement; what, if any, community resources will be utilized, how to re-enter services of needed, client and staff dated signature. The facility director will be responsible to train staff in how to utilize the new form. The facility director will utilize the agency EMR to track compliance. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information as per agency policy in two of two client records.
The findings include:
Three discharged outpatient client records were reviewed on July 31, 2013. Two of the three discharged clients have been discharged for the amount of time required for follow up contact. Per agency policy, follow up contact will be completed within 15 days of discharge for clients that successfully completed the program. Follow-up will be documented within 30 days of discharge fro non-routine discharges. Follow up was not documented within 15 days of discharge in client records # 2 and 3.
Client #2 was admitted on February 13, 2013 and successfully discharged on May 25, 2013. A follow up contact was due to be completed by June 9, 2013. There was no follow up contact documented in the client record as of the date of the inspection.
Client # 3 was admitted on March 16, 2013 and successfully discharged on June 29, 2013. A follow up contact was due to be completed by July 14, 2013. There was no follow up contact documented in the client record as of the date of the inspection.
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Plan of Correction
The facility director will create and implement a form to track the follow up contacts for discharged clients. THe form will include: client name, client number, DOA/DOD and DOD status; a table outlining the intervals contacts are due as outlined in the agency policy. THe form will document: date the contact was attempted, what means of communication (phone call, email, regular mail); the outcome of the contact effort and a signature line to document what staff member completed the follow up. The facility director will be responsible to train staff in utilization of the form; each staff member will be responsible to complete the follow up contacts with clients from their caseloads as outlined in the agency policy. The EMR will trigger a reminder the date follow up contacts are due. |