INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on August 23 - 25, 2010 by staff from the Division of Drug and Alcohol Program Licensure.
Based on the findings of the on-site inspection, Cora Services, 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 and a plan of correction is due on September 25, 2010.
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Plan of Correction
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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection and an interview with the Project Director, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
The findings include:
A physical plant inspection was conducted on August 25, 2010 at approximately 3:15 PM. It was observed that counseling sessions could be seen outside of all of the counseling rooms. An interview with the Project Director confirmed that the counseling offices lacked privacy and proper window treatment.
This surveyor was able to see 5 clients and 5 counselors engaged in counseling sessions on separate occasions.
None of the counseling rooms ensured privacy, as they have a small window that lacks window treatment.
The Project Director stated, "No, the windows will not receive window treatment." She then said that the Division of Drug and Alcohol Program Licensure was the Department that required/recommended the doors/windows that do not ensure privacy. She said this was recommended/required by the Department to ensure safety. Lastly, she stated that she will have to contact Harrisburg and the Director of Drug and Alcohol Program Licensure.
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Plan of Correction
This issue was presented to the Board and Administration, who expressed safety concerns, as the intent to insure privacy in the safest manner for clients, visitors and staff alike has been demonstrated. At their direction, a request for exemption to this standard was submitted to the Department on 9/9 for consideration at the 9/10 meeting.
In the event that the exemption is not approved, CORA will arrange to have window treatments installed. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant inspection, a review of the facilities policy and procedures manual, and a interview with the Project Director, the facility failed to secure client records within locked storage containers.
The findings include:
The facilities policy states that drug and alcohol files will be locked in a secure medical records room.
A physical plant inspection was conducted on August 25, 2010 at approximately 3:15 PM. The client records room was observed with a door wide open. The surveyor proceeded into the client record room and observed one of the file drawers unlocked and open and other file drawers unlocked with the key in the lock.
An interview was conducted with the Project Director.
The Project Director stated, "No" the record room nor the client file drawers will be locked during business hours because the records need to be accessible to staff.
The Project Director said that the regulation was subjective and that the records being unsecured within unlocked storage containers was not an issue before.
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Plan of Correction
To avoid future issues on this subject, the file cabinets containing SA treatment client records have been locked and remain so except when in direct use, and authorized staff have access to them only by passkey. Effective date is 10/1/10.
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709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, a review of the facilities policy and procedures manual, and an interview with the Project Director, the facility failed to document a complete client record.
The findings include:
The facilities policy titled "Service Follow-Up" states:
Follow-up is a very important recovery support service that staff can offer to clients who wish it and all client records include attempts to follow-up with clients who have completed service or terminated service for any reason. Consequently, the following procedures become effective upon termination...
Counselor contacts client by phone 30 days post termination and completes follow-up form.
Counselor files follow-up form in client's file and notes contact on service record and proceeds with necessary action steps if any.
Eight client records were reviewed on August 24, 2010.
Four client records were required to document follow-up.
The facility failed to document a complete client record including follow-up information in client records # 5, 6, 7, and 8.
Client # 5 was admitted to the program on 1/5/10 and discharged on 6/22/10.
At the time of review on 8/24/10 the facility failed to document follow-up information.
Client # 6 was admitted to the program on 1/12/10 and discharged on 7/7/10.
At the time of review on 8/24/10 the facility failed to document follow-up information.
Client # 7 was admitted to the program on 12/14/09 and discharged on 5/12/10.
At the time of review on 8/24/10 the facility failed to document follow-up information.
Client # 8 was admitted to the program on 1/28/10 and discharged on 6/9/10.
At the time of review of 8/24/10 the facility failed to document follow-up information.
The Project Director stated during an interview on August 24, 2010 that follow-up is documented in a follow-up book.
She then stated that the employee that documents follow-up is unavailable.
The Project Director stated that she does not know where the book documenting client follow-up is located.
This is a repeat deficiency. The facility received this deficiency during the September 17, 2008 inspection.
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Plan of Correction
Follow-up forms were maintained in a file separate from individual client records so that responses or further assistance might be more easily tracked. The file containing those forms was misfiled and the person who maintained that file was unavailable during the site visit. The file was subsequently located after the survey was completed.
To avoid reoccurrence of this issue, the procedure for follow-up has been modified to include notice of staff action due provided by the secretary, staff notation of any action in the Client Service Record, and staff filing of the FollowUp document in the client file upon completion. The secretary will monitor compliance with timelines and inform staff and supervisors of action due dates. This procedure becomes effective on October 1, 2010. |