INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ACCE & Associates LLC dba Recovery Works-PA 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) (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 a review of the July, 2023 through January, 2024 fire drill logs during the inspection, the facility failed to document exit route, problems encountered, and whether the fire alarm or smoke detector was operative at the time of the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill log has been updated to include: 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 new form was shared with the office manager and she was educated via verbal conversation and email on the new documentation requirements. Project director will review the log submissions to ensure the data is collected each month. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the July, 2023 through January, 2024 fire drill logs during the inspection, the facility failed to document whether a fire alarm or smoke detector was set off during the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A request for exemption was submitted on 3/5/24.
Details of the request: Request for exemption for regulation 705.28 (d) (7). The facility is part of a row of office suites and the fire alarm cannot be activated without impacting/disrupting the neighboring offices.
We are requesting an exemption for the longest possible duration/indefinitely as the alarm structure will not be modified for the time we are operating at this location.
To comply with the regulation, we have obtained a handheld device (electronic megaphone) with a very loud alarm sound that can be utilized to replicate the fire alarm. Rather than activate the building alarm, we will use the device to alert people in the office to evacuate and follow emergency procedures.
If the exemption is not granted, the Project director will collaborate/consult with the Licensing Specialist team to determine how to meet the regulatory requirements. |
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 a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in four out of four records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #1 was admitted on November 17, 2023 and was still active at the time of the inspection.
Client #2 was admitted on October 13, 2023 and was still active at the time of the inspection.
Client #3 was admitted on December 22, 2023 and was still active at the time of the inspection.
Client #4 was admitted on December 13, 2023 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The release of information for funding source was updated and sent to clients 1-4 via their EMR client portal following education of the form updates. Prompts were added to an initial session document to ensure the releases are reviewed to ensure completion. Office manager was educated verbally and in email about the form updates and new procedures for ensuring the correct form is used. Old releases were archived. The Project director will complete monthly chart audits to ensure new admission releases are present and complete. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the specific information to be disclosed in two out of four records reviewed.
Client #2 was admitted on October 13, 2023 and was still active at the time of the inspection. A release of information form was signed and dated on October 12, 2023 to an emergency contact that did not include the specific information to be disclosed.
Client #4 was admitted on December 13, 2023 and was still active at the time of the inspection. A release of information form was signed and dated on December 13, 2023 to an emergency contact that did not include the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Informed voluntary consent forms were updated with specific prompts related to information to be disclosed to ensure consistent completion. Consents were resent to clients to sign via their EMR client portal. Old forms have been archived. Office manager was educated around the form updates verbally and in email. Project director will complete monthly chart audits to ensure new admissions and annual updates are completed per regulation requirements. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the purpose of the disclosure in one out of four records reviewed.
Client #2 was admitted on October 13, 2023 and was still active at the time of the inspection. A release of information form was signed and dated on October 12, 2023 to an emergency contact that did not list the purpose of disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Informed voluntary consent forms were updated with specific prompts related to purpose of the disclosure to ensure consistent completion. Consents were resent to clients to sign via their EMR client portal. Old forms have been archived. Office manager was educated around the form updates verbally and in email. Project director will complete monthly chart audits to ensure new admissions and annual updates are completed per regulation requirements. |
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 client records, the facility failed to include documentation that clients have been notified of all the required client rights, including the project may not discriminate in the provision of services on the basis of creed, ethnicity or handicap in four out of four records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client rights document was updated to include creed, ethnicity or handicap. The form was resent to the clients via EMR portal. Office manager was educated verbally and via email about the updates. Project manager will complete monthly chart audits to ensure new admissions have completed the form. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document that client orientation to the project included the fee schedule in four out of four records reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A new form called Notice of Financial Agreement was developed to outline the financial cost, fee schedule and expectations of payment for clients. This form was sent to all clients via their EMR client portal for signature. The office Manager was educated verbally and in email around the new form and procedures. The Project director will complete monthly chart audits to ensure this form accompanies the initial forms completed as part of intake. |