INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 17, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Casa de Consejeria y Salud Integral, 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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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 facility's May 2020 through April 2021 fire drill log, the facility failed to ensure that their written fire drill log included the time of the drill and the exit route used during drills. The fire drill logs for September 2020 through December 2020 failed to document the exit route used. Additionally, the fire drill log for January 2021 failed to document the time of the drill. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager/coordinator under the supervision of the facility director will ensure that all fire drill logs are completed accurately on a monthly basis. The facility director will also re-train the office manager on completing the logs correctly by including date, time of drill, number of people, amount of time of evacuation, and exits used during evacuation. The facility director will also review each log after the fire drill is completed. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the facility failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has contacted an independent public accountant who will have our 2019 financial audit completed by the date indicated above. The Executive Director will make sure to secure the commencement of future audits no later than May 31 through an engagement letter and completed by June 30. |
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
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on release of information forms in three of nine client records reviewed. Client # 1 was admitted on November 5, 2020 and was still active at the time of inspection. The release of information form to a primary care physician was signed by the client and witness on January 16, 2020, but the form did not document the name of the person, agency, or organization to whom the disclosure was to be made. Client # 5 was admitted on January 2, 2020 and was discharged on December 23, 2020. The release of information form to a primary care physician was signed by the client and witness on October 15, 2020, but the form did not document the name of the person, agency, or organization to whom the disclosure was to be made. Additionally, the client record contained a blank release of information form that was signed by the client and witness on October 15, 2020. Client # 8 was admitted on November 24, 2020 and was still active at the time of inspection. The release of information form to a primary care physician was signed by the client and witness on November 24, 2020, but the form did not document the name of the person, agency, or organization to whom the disclosure was to be made. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The clinical supervisor will hold an in-service training to discuss timely revisions and checks of releases of information in order to prevent expiration or lapses of time while a client is active in our program. The training will focus on including the specific name of PCP and not keep it general by only indicating "PCP". Active charts will be audited in order to rectify any ROIs out of compliance and active clients will sign a new ROI to the PCP.
The in-service will also discuss essential information and forms which will facilitate compliance to general guidelines of client confidentiality framed by 4 Pa Code 255.5 regulations and 42 CFR Part 2, including the Health Insurance Portability and Accountability Act (HIPPA) The nature of the release and the circumstances by which the information may be released, the specific content and limited nature of the information to be disclosed, to whom specifically, the purpose of the disclosure, the method of releasing the information as well as the timeframes for the release, signature of client and witness, date of signatures and whether the client has received a copy. This will be completed by 7/16/21.
Clinical staff shall continue to attend recommended Department of Health training and provide documentation in areas such as confidentiality and client recordkeeping. This will be monitored by HR on an annual basis. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility's October 2020 through April 2021 unusual incident logs, the facility failed to file a written unusual incident report with the Department within 3 business days following an incident that required the presence of police and/or ambulance personnel at the facility on January 8, 2021.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director will meet and conduct an in-service training with the facility directors regarding the unusual incident reporting policy to ensure that we are not only completing unusual incident reports when the presence of police and/or ambulance personnel is required but also sending them to the Department within three business days of the incident. The incident documented on January 8, 2021 will be reported to DDAP by July 9, 2021. To ensure this incident will not reoccur, all significant incidents reports must be securely emailed to the project director within 4 days of the incident with an attached written verification that the incident has been reported to DDAP within the three-business day timeframe. The verification will include day and time of report sent and name and signature of the individual who sent the report. All reports will be reviewed by the facility director prior to submission to DDAP and the Project Director.
The in-service training will be conducted no later than 7/16/21. |