INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18 - 19, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHJ Medical Center, 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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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the 2011 annual report and administrative documentation, the governing body failed to make the 2011 annual report available to the public.
The findings include:
The annual report for January 1 through December 31, 2011 was reviewed on March 18, 2013. The facility is publicly funded and the governing body is required to make the annual report available to the public. There was no documentation that the 2011 annual report was made available to the public, as of March 18, 2013.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The project director is responsible to ensure publication and maintain documentation of the publication of the availablity of the annual report to the public. In order to maintain compliance with this standard a folder will be created that will be maintained by the project director to include a copy of the public notification that the annual report may be obtained, which will be made available to the department upon inspection. Due to the noncompliance for 2011 the facility will, upon completion of the 2012 annual report, publish the availability of the report to the public for both 2011 and 2012. A copy of the publication will be placed in the folder for inspeciton. Also reminders will be set annually to ensure that the facility is compliant with this standard. |
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 from the client for the disclosure of information contained in the client record in seven of seven client records.
The findings include:
Sixteen client records were reviewed on March 18 - 19, 2013. Seven client records were reviewed for informed and voluntary written consents from the client. 42 CFR Part 2, Subpart C, subsection 2.31 (a)(8), requires a statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it. The consent can be revoked by the client verbally or in writing. The facility's consents to release information include the following statement: "I understand that I may revoke this consent at any time, it must be in writing". This is in violation of federal confidentiality regulations. The facility failed to obtain an informed and voluntary consent to release information from the client in client records # 1, 3, 5, 6, 7, 8 and 9.
The project/facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The project director is responsible to ensure compliance with this standard. In order to become and maintain compliance the project director will revise the statement on all of the faciliy releases of information to include the statement that the releases may be revoked verbally or in writing at any time. All old releases will be replaced with the new releases. The project director will meet with staff to inform them of this change so that they replace all copies with the new document. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. 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:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that included long term goals for treatment in five of seven clients records.
The findings include:
Sixteen client records were reviewed on March 18 - 19, 2013. Seven client records were reviewed for treatment plans that included long term treatment goals. The facility failed to document long term treatment goals in client records # 5, 6, 7, 8 and 9.
Client # 5 was admitted into treatment on December 18, 2012. The treatment plan for client # 5 was completed on January 17, 2013. The treatment plan did not include long term treatment goals.
Client # 6 was admitted into treatment on December 4, 2012. The treatment plan for client # 6 was completed on January 3, 2013. The treatment plan did not include long term treatment goals.
Client # 7 was admitted into treatment on October 5, 2012. The treatment plan for client # 7 was completed on November 5, 2013. The treatment plan did not include long term treatment goals.
Client # 8 was admitted into treatment on December 21, 2012. The treatment plan for client # 8 was completed on January 17, 2013. The treatment plan did not include long term treatment goals.
Client # 9 was admitted into treatment on January 25, 2013. The treatment plan for client # 9 was completed on February 22, 2013. The treatment plan did not include long term treatment goals.
The clinical supervisor was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The project director is responsible to ensure compliance with this standard. In order to achieve and maintain compliance the treatment plan will be revised to include a long term treatment plan goal. This new treatmnet plan will then replace the previous treatment plan. The project director will meet with clinical staff to provide the revised document and make them aware that this will replace the previous document. |