INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20-21, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Libertae Family House Libertae, Inc. 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on the review of personnel records, the facility failed to document that staff persons received a minimum of and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in one of twenty-nine personnel records.
The findings include:
Personnel records were reviewed on May 18, 2015. Twenty-nine personnel records were reviewed for the completion of at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training. The training was not documented in one of twenty-nine personnel records.
For one of twenty-nine personnel records, the employee was hired on 7/10/2010 and is employed in the maintenance department. The tuberculosis, sexually transmitted diseases and other health related topics training was due to be completed by July 19, 2012. There was no documentation that the employee completed the training.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The responsible party is the Assistant Director.
The Assistant Director informed the staff of the missing training and required he attend the next training scheduled on 6/11/15. The Assistant Director had this staff registered for the training in May, 2015.
The one staff whose record did not reflect this training attended the TB/STD on June 11, 2015 at Livengrin Foundation. A certificate was obtained and is in his personnel file.
The Assistant Director will remind all staff of mandatory trainings at the next staff meeting to be held on July 6, 2015. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill log, the facility failed to indicate whether fire alarms or smoke detectors were operative during each fire drill.
The findings include:
Fire drill logs were reviewed on May 21, 2015. Fire drill documentation was reviewed from May 2014 through April 2015. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been activated for the fire drills. This documentation was missing on five fire drills that were reviewed, dated for 7/9/14, 10/5/14, 11/10/14, 12/11/14, and 3/11/15.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The responsible party is the Director of Operations.
The Director of Operations reviewed all fire logs at the June 8, 2015 Operations Department Meeting.
The Director of Operations will monitor the fire logs by doing quarterly checks of the fire logs to verify they are completed correctly.
During all these documented drills it was verified that the alarms were activated and working correctly, however, documentation of this was not completed in its entirety.
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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 a review of client records, the facility failed to obtain an informed and voluntary consent which documented the purpose of the disclosure, the dated signature of the client or guardian as provided for under 42 CFR 2.31 (relating to form of written consent), and the dated signature of a witness in four of six client records.
The findings include:
Six client records which required documentation of an informed and voluntary consent were reviewed on May 20, 2015. The facility failed to obtain an informed and voluntary consent which documented the purpose of the disclosure in client records # 1, 3, 4, and 5. The facility also failed to document the dated signature of the client or guardian as provided for under 42 CFR 2.31 (relating to form of written consent) in client record # 4. Additionally, the facility failed to document the dated signature of a witness in client record # 5.
Client #1 was admitted into treatment on 1/14/15 and was still active at the time of the inspection. Two consent to release information forms, both signed by the client on 2/2/15, did not clearly specify the purpose of the disclosure. On both consent forms, the facility documented that the purpose of the disclosure was "to take messages".
Client #3 was admitted into treatment on 2/5/15 and was still active at the time of the inspection. A consent to release information form for the client's mother, signed by the client on 2/5/15, did not clearly specify the purpose of the disclosure. The facility only documented that the purpose of the disclosure was "to take messages". Additionally, the client's record contained a consent to release information form that documented both a CYS caseworker and the client's mother as the person, agency, or organization to whom disclosure was made.
Client #4 was admitted into treatment on 7/9/14 and discharged on 1/7/15. A consent to release information form for a counseling agency was not signed by the client, and only contained the counselor's signature. The facility documented that the purpose of disclosure was for the counseling agency to receive the client's discharge summary. The facility documented on the client signature line "client left without signing". Additionally, the client's record contained five consent to release information forms that did not clearly specify the purpose of the disclosure. On the five consent forms, the facility documented that the purpose of disclosure was "to take messages" or "to take a message".
Client #5 was admitted into treatment on 10/7/14 and was discharged on 3/6/15. The facility failed to clearly document the purpose of disclosure on two consent to release information forms. On the two consent forms, the facility documented that the purpose of disclosure was "to take messages" or "to take a message". Additionally, the client's record contained one consent to release information that did not have the dated signature of a witness.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The responsible party is the Clinical Director.
On June 8, 2015 the Clinical Director included a refresher discussion with all clinicians and clinical graduate interns on consent to release information forms.
Specific areas covered in the refresher were "the Purpose of the consent" for client #1 and #3 and signatures needed for client#4 and the need for witness signature for client # 5. As well as there needing to be separate consents for each individual or agency needing the disclosure of information as on client #3's form.
The Clinical Director will add this Consent to release information refresher training to the Clinical graduate intern orientation held no later than October 2015 and will carry it over annually.
The Clinical Director will monitor the ongoing compliance around consents to release information in Quarterly chart reviews and during monthly 1:1 supervision sessions with primary clinicians. The clinicians will also monitor compliance in their impromptu peer chart reviews monthly.
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709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to consistently ensure that the client was offered a copy of the consent to release information form upon signing in two of six records reviewed.
The findings included:
Six client records requiring releases of information were reviewed on May 20, 2015. The facility failed to provide verification that the client was offered a copy of the consent in client records # 5 and 6.
Client #5 was admitted into treatment on 10/7/14 and was discharged on 3/6/15. The client's record contained a consent to release information form that did not document that the client was offered a copy of the consent form.
Client #6 was admitted into treatment on 9/8/14 and was discharged on 2/17/15. A consent to release information form for DPW, signed by the client on 9/8/14, did not document that the client was offered a copy of the consent form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The responsible party is the Clinical Director.
On June 8, 2015 the Clinical Director held a Clinical Department meeting with all clinicians and Clinical Graduate Interns. Specific incidences discussed were client records #5 & #6
A refresher training discussion was held on consent to release information which included the need to indicate on all consents that the client received a copy of the consent to release information.
The Clinical Director and clinicians will review the consent to release information forms during quarterly chart reviews and impromptu peer chart reviews to ensure their accuracy. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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
Based on a review of client records, the facility failed to document the type and frequency of treatment services on the individual treatment and rehabilitation plan in five of six records reviewed.
The findings include:
Six client records requiring documentation of the type and frequency of treatment services on the individual treatment and rehabilitation plans were reviewed during the renewal inspection. The individual treatment and rehabilitation plans contained in client records # 1, 2, 3, 4, and 5 did not specify the type and frequency of treatment services.
Client #1 was admitted into treatment on 1/14/15 and was still active at the time of the inspection. The client's individual treatment and rehabilitation plan dated 2/14/15 did not specify the type and frequency of treatment services.
Client #2 was admitted into treatment on 1/14/15 and was still active at the time of the inspection. The client's individual treatment and rehabilitation plan dated 2/14/15 did not specify the type and frequency of treatment services.
Client #3 was admitted into treatment on 2/5/15 and was still active at the time of the inspection. The client's individual treatment and rehabilitation plan dated 3/5/15 did not specify the type and frequency of treatment services.
Client #4 was admitted into treatment on 7/9/14 and was discharged on 1/7/15. The client's individual treatment and rehabilitation plan dated 8/9/14 did not specify the type and frequency of treatment services.
Client #5 was admitted into treatment on 10/7/14 and was discharged on 3/6/15. The client's individual treatment and rehabilitation plan dated 10/7/14 did not specify the type and frequency of treatment services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The responsible parties are the Clinical Director and the Assistant Director.
The Clinical Director met with the Assistant Director on Friday, May 22,2015 to discuss the plan to add "Type and Frequency" to the permanent electronic file template for all treatment plans.
The Clinical Director met with the one clinician that did not add "Type and Frequency" on client records #1, 2, 3, 4, & 5 during the regular scheduled supervision on June 4, 2015. This clinician was instructed to manually type in the Type and Frequency of client services on each treatment plan until the Electronic file template had it added permanently.
The Assistant Director contacted the Electronic Administrator of the electronic file program to request the addition on Friday, May 22, 2015.
The Clinical Director will monitor the progress of this permanent change to the electronic file template to include Type and Frequency by July 15, 2015. |