INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 7, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Oil Recovery Recovery, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to docment the name of the person, agency or organization to whom disclosure is made on all consents to release information.
Client #1 was admitted on November 28, 2023 and discharged on December 4, 2023. A signed consent to release information was documented in the client record; however, the signed consent to release infomation did not include a recipient. The area for the recipient of the information was left blank.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Inservice will be done by the Clinical Director on appropriately filling out the consent forms. Clinical Director and Program Assistant Supervisor will monitor charts for compliance. Inservice will be 6/18/24 |
709.32 (b) LICENSURE Medication control
§ 709.32. Medication control.
(b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
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Observations
Based on a review of client records, the facility failed to document a physician's signture on a verbal order.
Client #1 was admitted on November 28, 2023 and discharged on December 4, 2023. A verbal order taken by a nurse, documented on December 2, 2023 at 11:00 AM did not have documentation of a physician signature.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Nurse Manager will have meeting with Nursing staff on protocol to follow for Verbal orders. Inservice will be held 6/18/24 for nursing staff. Nurse manager will monitor and make sure all verbal orders are signed within 24 hours in detox and within 72 hours for residential. |
709.63(a) LICENSURE Client record
709.63. 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:
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Observations
Based on a review of a client admission and discharge list, the facility failed to document a complete client record which included information relative to the client's involvment with the project.
A list of current and discharged clients was requested and client records were selected for review. One client record was unable to be located. This client was admitted to detox on October 5, 2023 and discharged on October 9, 2023.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Clinical Director will train staff on 6/18/24 on the process for closing charts and where they are filed when they are closed out. If anyone wants a chart out of the chart cabinet after being closed they will be signing them out and then signing them back in. This will be monitored by the Clinical Director for compliance. |