INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 5-6, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tadiso, 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) (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
Based on a review of the fire drill logs, the facility failed to conduct unannounced fire drills at least once per month for three of nine months reviewed.
The findings include:
The fire drill logs from November 2013 to July 2014 were reviewed on August 6, 2014. There was no documentation of unannounced fire drills for the months of February 2014, March 2014 and July 2014.
The Project/Facility Director was interviewed on August 6, 2014 and confirmed the findings.
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Plan of Correction
Building supervisor will maintain fire drill log and be responsible for pulling fire drill, accumulating necessary data for the fire drill log, and recording such information in the fire drill log. A fire drill was conducted on August 21, 2014 and information was enterd into the log. The building supervisor will be responsible forconducting the remaining monthly fire drills. The safety commity, which meets quarterly will review the fire drill log information and make any necessary changes to the procedures for fire safety. |
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 fire drill logs, the facility failed to maintain a written fire drill record that included the amount of time it took for evacuation and the exit route used.
The findings include:
The fire drill logs from November 2013 to July 2014 were reviewed on August 6, 2014. The fire drill logs that were documented did not include the amount of time it took for evacuation nor the exit route used.
The Project/Facility Director was interviewed on August 6, 2014 and confirmed the findings.
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Plan of Correction
A new fire drill log was created on August 20, 2014 which includes date of drill, time of drill, exits used during drill, number of persons at facility during the drill, problems encountered during drill, whether or not fire and smoke detectors are working properly and the time needed to evacuate the premises. These fire drill log sheets will be kept in a designated area and managed by the building supervisor. The building supervisor is responsible for pulling the drill, collecting the data and completing the data log sheet. |
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 the review of client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information contained in the client record in four of fifteen client records.
The findings include:
Fifteen client records were reviewed on August 5-6, 2014. Fifteen clients records required documentation of an informed and voluntary consent. Documentation of informed and voluntary consents were not documented in client records # 7, 8, 13 and 14.
Client # 7 was admitted on March 17, 2014 and discharged on July 10, 2014. There was no documentation of an informed and voluntary consent from the client for the release of information to the third party payer.
Client # 8 was admitted on January 23, 2014 and discharged on July 21, 2014. There was no documentation of an informed and voluntary consent from the client for the release of information to the third party payer.
Client # 13 was admitted on December 11, 2013. There was no documentation of an informed and voluntary consent from the client for the release of information to the third party payer.
Client # 14 was admitted on January 29, 2014. There was no documentation of an informed and voluntary consent from the client for the release of information to the third party payer.
The Project/Facility Director and Clinical Supervisor were interviewed on August 6, 2014 and confirmed the findings.
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Plan of Correction
Procedures for the intake process have been changed to include a face to face meeting with the Tadiso fiscal deparment at which time required release forms will be completed which will allow information to be released to third pary payers. Also, all current patients who do not have the requried consent forms will be escorted to the fiscal department by their primary counselor in order to complete required release forms to allow release of information to third party payers. The quality assurance coordinator will oversee this process to insure that all patients have the required consent forms completed. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document a preliminary treatment and rehabilitation plan in five of fifteen client records.
The findings include:
Fifteen client records were reviewed on August 5-6, 2014. Fifteen client records required documentation of a preliminary treatment and rehabilitation plan. There was no preliminary treatment and rehabilitation plan documented in client records # 7, 8, 13, 14 and 15.
Client # 7 was admitted on March 1, 2014 and discharged on July 10, 2014. There was no documentation of a preliminary treatment and rehabilitation plan.
Client # 8 was admitted on January 23, 2014 and discharged on July 21, 2014. There was no documentation of a preliminary treatment and rehabilitation plan.
Client # 13 was admitted on December 11, 2013. There was no documentation of a preliminary treatment and rehabilitation plan as of August 6, 2014.
Client # 14 was admitted on January 29, 2014. There was no documentation of a preliminary treatment and rehabilitation plan as of August 6, 2014.
Client # 15 was admitted on March 14, 2014. There was no documentation of a preliminary treatment and rehabilitation plan as of August 6, 2014.
The Project/Facility Director and Clinical Supervisor were interviewed on August 6, 2014 and confirmed the findings.
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Plan of Correction
A preliminary treatment and rehabilitation plan will be scheduled in the electronic record as part of the intake process and will be completed during the intake process by the intake counselor. The quality assurance coordinator will monitor all new intakes to insure that a preliminary treatment and rehabilitatin plan has been completed. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on the review of client records, the facility failed to document an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services in four of fifteen client records.
The findings include:
Fifteen client records were reviewed on August 5-6, 2014. Fifteen client records required documentation of an individual treatment and rehabilitation plan. There was no documentation of the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in client records # 2, 8, 13 and 14.
Client # 2 was admitted on December 5, 2013. The individual treatment and rehabilitation plan, completed on January 10, 2014, did not include the type and frequency of treatment and rehabilitation services.
Client # 8 was admitted on January 23, 2014. The individual treatment and rehabilitation plan, completed on January 23, 2014, did not include the type and frequency of treatment and rehabilitation services.
Client # 13 was admitted on December 11, 2013. The individual treatment and rehabilitation plan, completed on December 27, 2013, did not include the type and frequency of treatment and rehabilitation services.
Client # 14 was admitted on January 29, 2014. The individual treatment and rehabilitation plan, completed on January 29, 2014, did not include the type and frequency of treatment and rehabilitation services.
The Project/Facility Director and Clinical Supervisor were interviewed on August 6, 2014 and confirmed the findings.
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Plan of Correction
The standard was reviewed in the Social Services department meeting on August 14, 2014 by the Director of Social Services and examples of the types and frequency of services was provided for each counselor. Clinical supervisors will review each treatment plan to insure that the type and frequency of services is indicated and if not, the treatment plan will be sent back to the counselor for revision. |
709.93(a) 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:
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Observations
Based on the review of client records, the facility failed to document a complete client record that included case consultation notes in five of ten client records.
The findings include:
Fifteen client records were reviewed on August 5-6, 2014. Ten client records were reviewed for case consultation notes. Case consultations were not documented in client records # 7, 8, 13, 14 and 15.
Client # 7 was admitted on March 17, 2014. A case consultation note dated June 13, 2014 did not include documentation of participants. The note was signed by the counselor on June 13, 2014 and the supervisor on June 16, 2014.
Client # 8 was admitted on January 23, 2014. A case consultation note dated April 23, 2014 did not include documentation of participants. The note was signed by the counselor and the supervisor on May 2, 2014.
Client # 13 was admitted on December 11, 2013. A case consultation note dated March 11, 2014 did not include documentation of participants. The note was signed by the counselor on March 11, 2014 and the supervisor on March 12, 2014.
Client # 14 was admitted on January 29, 2014. A case consultation note dated April 29, 2014 did not include documentation of participants. The note was signed by the counselor and the supervisor on May 2, 2014. A case consultation note dated July 16, 2014 did not include documentation of participants. The note was sign by the counselor on July 16, 2014 and the supervisor on July 17, 2014.
Client # 15 was admitted on March 14, 2014. A case consultation note dated June 13, 2014 did not include documentation of the participants. The note was signed by the counselor on June 23, 2014 and the supervisor on June 24, 2014.
The Project/Facility Director and the Clinical Supervisor were interviewed on August 6, 2014 and confirmed the findings.
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Plan of Correction
This standard was reviewed in the Social Services department meeting on August 14, 2014 by the Director of Social Services. Counselors were instructed to schedule each consultation with a supervisor or the clinical team which consists of a supervisor, counselor and medical director or physician assistant. The quality assurance coordinator will review all patient records at least twice a year to insure compliance. |