INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Northern Tier Counseling, Inc. was found to not 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
The facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
The facility ' s two fire extinguishers were last inspected in September of 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The local fire inspector did come in on October 15, 2018 to inspect all the fire extinguishers at the Drug and Alcohol treatment facility. Next year our computer system is slated to remind us to call the local fire inspector agency "Action Fire and Safety on September 1, 2019 at 607-775-0061. In the future there is an alert within our electronic health record system that will go to the support staff supervisor Renee Ritz as a reminder 2 months prior to the due date of the Drug and Alcohol inspection to ensure the local fire chief is called as a reminder to complete the fire extinguisher inspection timely. All current fire extinguishers are fully charged and in good condition. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct unannounced fire drills at least once a month.
The facility failed to conduct a fire drill for the month of April 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NTC is now utilizing an electronic health record, and now are able to insert alerts to complete mandatory tasks, the fire drill reminder will be added to alert the fiscal and support staff to complete monthly fire drills in the building, to which will not be removed until the fire drill is completed, monthly. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa Code 255.5(b) for releases of information in one client record.
Client #5 was admitted on 5/14/2018 and was active at the time of the licensing inspection. There was a signed consent for billing purposes with no name of the person, agency or organization to whom the disclosure was to be made for the release.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NTC is now utilizing an electronic health record, which will not allow a form, in particular consents/releases, to be signed unless the form is completed thoroughly, which would eliminate this from occurring again; the form has to include all identifying information, including name. agency/organization and purpose for the release prior to the signature to finalize the consent. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written acknowledgement in four out of seven client charts that they had been notified of their rights as written in the policies and procedures of the project.
Client #1 was admitted on October 23, 2017 and was discharged on March 19, 2018. There was no documented written acknowledgement that the client had been notified of their rights per the project's policies and procedures.
Client #2 was admitted on December 11, 2017 and discharged on April 23, 2018. There was no documented written acknowledgement that the client had been notified of their rights per the project's policies and procedures.
Client #3 was admitted on December 5, 2018 and was discharged on April 3, 2018. There was no documented written acknowledgement that the client had been notified of their rights per the project's policies and procedures.
Client #4 was admitted June 8, 2017 and was discharged on January 19, 2018. There was no documented written acknowledgement that the client had been notified of their rights per the project's policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
NTC is now utilizing an electronic health record, and the intake documents are all included in a group format, which requires every document to be reviewed and signed before an intake can be completed. The client rights are included in the group document at intake and is required to be reviewed before the intake assessment can be completed and signed off on. |