INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 19, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of seven client records, the project failed to document written acknowledgement by clients that the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
Client #2 was admitted on February 12, 2020 and was current at the time of the inspection. There was no written acknowledgement documented that client #2 was informed of their client rights.
These findings were reviewed with the project staff during the licensing process.
This is a repeat citation from annual licensing inspection held on September 9, 2019.
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Plan of Correction
In the transition from paper charts to electronic charts this Consent to Treatment had been misplaced.
To correct the citation, the facility director will add the DDAP copy of Consent to treatment, client rights to the existing consent to treatment in the EMR.
The assigned clinician will send an email to client(s) prior to the initial session for client(s) to review, and sign off electronically.
The EMR then uploads the completed forms to the specific client record.
When the consent to treatment is completed an email is sent to the assigned clinician to confirm completion. Is this is not completed prior by the intake appointment, the assigned clinician will resend the forms for completion.
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