INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2016 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection and conversation with facility staff the facility failed to ensure fire extinguishers are inspected and approved annually.
The fire extinguisher located in Suite 100, which is occasionally utilized by the facility to accommodate group counseling sessions, was not currently inspected. The inspection tag was expired as of June 2015.
This information was reviewed with the facility staff.
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Plan of Correction
The land lord has been contacted to have the fire extinguisher inspected and brought current.
The room will not be utilized until the fire extinguisher has been brought current. |
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.
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Observations
Based on the review of client records, the facility failed to limit the release of information to what is permissible according to 4 Pa. Code 255.5 in one client records.
4 Pa. Code states that 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 the code, 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.
Additionally, a consent form in client record #1 was missing the client's signature and two consent forms in client record #3 were missing the witness signature .
Client record #1 had a consent to release information form dated August 13, 2015, to a funding source, that was not signed by the client at the time of the ingestion.
Client record #2 had a consent to release information form to funding sources dated December 16, 2015, that had "Continuing care plan, Psychosocial, discharge summary, legal status, Medication list, Medication history, Nursing assessment, PPD results" checked as information that could be released, which exceeds the limits imposed by 4 Pa. Code record #3 had two consent to release information forms dated March 21, 2016, one to a funding source and one to a government agency, that were not signed by witness.
The information was reviewed with facility staff.
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Plan of Correction
The facility director will destroy all electronic and paper consents created prior to July 2016 immediately.
The facility director will utilize the updated consents created in July 2016 in both electronic and paper formats.
The facility director will complete all software updates to ensure electronic forms print correctly.
The facility director will hire a contract staff member for the purpose of quality assurance. This contract staff person will not participate in clinical tasks; rather monitor compliance of current and closed charts for compliance with: policy accuracy of forms; chart compliance of required paper work. This individual will review charts on a quarterly basis and will be hired before September 30th, 2016.
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709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records and a conversation with facility staff the facility failed to document a consent to treatment in two of ten client records.
Client records #2 and #3 contained no documentation that a consent to treatment form was reviewed with or signed by the client during the intake period.
This information was reviewed with the facility staff.
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Plan of Correction
The facility director will hire a contract staff member to review charts for accuracy and compliance. This person will be hired by September 30th, 2106 and will conduct chart reviews on a quarterly basis.
The facility director will create a chart auditing for this individual to utilize to complete charts review; noting what is or is not present; as well as a space for this individual to sign and date when the chart review was completed
The facility director will review charts noted with deficiencies; in turn having the counselor bring the charts current within 2 weeks of their. This allows the counselor an opportunity to meet with clients if their involvement in resolving the deficiency is needed.
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709.92(a) 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:
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Observations
Base on a review of client records the facility failed to document a individual treatment and rehabilitation plan in two of ten client records. Additionally, the facility failed to include the type and frequency of treatment on the treatment and rehabilitation plan in four of ten records and failed to obtain the client's signature in two of ten records reviewed.
Client record #1 contained a comprehensive treatment plan dated August 24, 2015 however, there was no documentation of the type and frequency of treatment being offered. Additionally there was no documentation that the client signed the treatment plan.
Client record #2 contained a comprehensive treatment plan dated December 31, 2016 [sic] however, there was no documentation of the type and frequency of treatment being offered. Additionally there was no documentation that the client signed the treatment plan.
Client record #3 contained comprehensive treatment plan dated July 11, 2016 however, there was no documentation of the type and frequency of treatment being offered.
Client record #5 contained comprehensive treatment plan dated May 12, 2016 however, there was no documentation of the type and frequency of treatment being offered.
Client #7 was admitted on July 22, 2015. Client record #7 contained no documentation of a comprehensive treatment plan being developed as of the date of the inspection.
Client #9 was admitted on July 16, 2015. Client record #9 contained no documentation of a comprehensive treatment plan being developed as of the date of the inspection.
This information was reviewed with facility staff.
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Plan of Correction
The facility director will move the type and frequency of services to the top of the treatment plan to reduce it being overlooked.
In addition, the facility director will utilize a contracted non clinical staff member to review charts on a quarterly basis going forward. This contracted staff member will review charts for compliance with required chart entries; and forms to completed with in required time frames. This contracted non clinical staff member will be hired by September 30, 2016
Any identified deficiencies found through the audit, will be review with the appropriate clinical staff by the facility director
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709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records the facility failed to ensure that treatment and rehabilitation plans were updated at least every 60 days in three of five applicable client records.
Client record #1 contained a comprehensive treatment plan dated August 24, 2015; a treatment plan update was due by October 24, 2015 however, there was no update documented until November 13, 2015. Additionally, a subsequent update was due by March 13, 2016 but was not completed until March 15, 2016; an update was due May 15, 2016 but was not completed until May 22, 2016.
Client record #5 contained a comprehensive treatment plan dated May 12, 2016; a treatment plan update was due by July 12, 2016 but no update was documented as of the date of the inspection.
Client #10 was admitted on July 30, 2015 and was discharged on May 6, 2016. Client record #10 contained a treatment plan update dated February 23, 2016; a treatment plan update was due by April 23, 2016 but no update was documented as of the date of the inspection.
This information was reviewed with the facility staff.
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Plan of Correction
THe facility director will review with direct clinical staff the format, time frame and requirements of the TPU - to completed within the 60 day time frame as outlined in the policy manual. Compliance with this change will be monitored by a the contracted non clinical staff member whom will be responsible to audit current and closed charts on a quarterly basis.
Any identified deficiencies will be reviewed with the appropriate clinical staff member for correction by the facility director.
The facility director will create a form to document when the charts are audited, the findings of the audit, and review with the appropriate clinical team member for correction.
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