INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29 - 30, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Abstinent Living at the Turning Point at Washington Women With Children 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
The facility failed to keep cold food at or below 40F and frozen food at or below 0F based on a physical plant inspection conducted on May 29, 2019 at 11:15 AM.The freezer in the Annex building had a temperature of 34F. This freezer was inspected again on May 30, 2019 and 8:45 AM and was 30F. Temperature logs were reviewed for May 2019 and showed the freezer temperature to be at or greater than 10F.The refrigerator in apartment # 5 had a temperature of 50F. This refrigerator was inspected again on May 30, 2019 at 10:30AM and was 50F. Temperature logs were reviewed for May 2019 and showed the refrigerator temperature to be greater than 40F.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager/Admissions Director confirms that there was an issue with the refrigerator/freezer in the Annex, and an issue with the refrigerator/freezer in Apartment 5. Both refrigerator/freezers were replaced on 5/29/19. The Operations Manager/Admissions Director will re-train all applicable staff on the importance of documenting temperatures in all refrigerator/freezers, and immediately notifying the Operations Manager/Admissions Director of any issues with said refrigerator/freezers. This will be overseen by the Project Director and the Operations Manager/Admissions Director. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
The facility failed to clearly indicate the second floor emergency exit in the Annex building by the use of a sign based on a physical plant inspection conducted on May 29, 2019 at approximately 11:30 AM.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager/Admissions Director confirms that the emergency exit sign was missing on the second floor of the Annex. The Operations Manager/Admissions Director ensured that the emergency exit sign was replaced immediately. In the future, the Operations Manager/Admissions Director will ensure that the appropriate emergency exit signs are properly in place during all walk-throughs. This will be overseen by the Project Director and the Operations Manager/Admissions Director. |
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.
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Observations
The facility failed to document a consent to release information form that was compliant with Federal confidentiality regulations by requiring the client to revoke their consent in writing in seven of seven client records reviewed on May 29 - 30, 2019. A consent to release information to a medical provider was documented during the intake process and included the following statement: "This authorization may be withdrawn at any time in writing".Client # 1 was admitted April 4, 2019.Client # 2 was admitted January 11, 2019.Client # 3 was admitted January 9, 2019.Client # 4 was admitted March 6, 2019 and discharged March 15, 2019. Client # 5 was admitted July 17, 2018 and discharged January 11, 2019. Client # 6 was admitted July 11, 2018 and discharged January 8, 2019. Client # 7 was admitted August 17, 2018 and discharged January 9, 2019. In addition, the facility failed to comply with Federal confidentiality regulations by not permitting the client to revoke their consent to release information at any time in client records # 4, 5, 6 and 7.These clients signed a form during the intake process that included the following statement: "I hereby acknowledge that I will not be permitted to withdraw my consent for any drug and alcohol program, county drug and alcohol court program and/or my probation officer".This statement is in violation of Federal confidentiality regulations as the client can revoke their consent for any drug and alcohol program at any time and also revoke their consent for the courts and probation unless the client was court mandated into treatment. There was no documentation of court ordered treatment in client records # 4, 5, 6 and 7.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manger/Admissions Director confirms that the consent form being used did include the language "This authorization may be withdrawn at any time in writing". Immediately upon being notified that said language is non-compliant, the consent form was changed to reflect that "This authorization may be withdrawn at any time."
The Operations Manager/Admissions Director confirms that there was language on our consent forms prohibiting a client from revoking the consent for "any drug and alcohol program, county drug and alcohol court program and/or my probation officer". Immediately upon being notified that this language is non-compliant, unless a client is court ordered to treatment and a copy of the court order is in the chart, the consent form was changed to eliminate that language.
The Operations Manager/Admissions Director will ensure that all consent forms are updated, as noted above. Additionally, the Operations Manager/Admissions Director will ensure that all applicable staff is re-trained on the importance of confidentiality and the requirement for proper consents prior to releasing any information regarding said clients. This will be overseen by the Project Director and the Operations Manager/Admissions Director.
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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 document the name of the person, agency or organization to whom disclosure is made on the written, informed and voluntary consent from the client in three of seven client records reviewed on May 29 - 30, 2019.Client # 5 was admitted July 17, 2018 and discharged January 11, 2019. The consent was signed July 17, 2018.Client # 6 was admitted July 3, 2018 and discharged January 8, 2019. The consents were signed July 3, 2018.Client # 7 was admitted August 17, 2018 and discharged January 9, 2019. The consents were signed August 17, 2018.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager/Admissions Director confirms that the name of the person, agency or organization to whom disclosure is made was not documented properly on the consent form. The Operations Manager/Admissions Director will ensure that all applicable staff is re-trained as to the information required on the consent form, and the importance of clearly documenting all required information. The Operations Manager/Admissions Director will also review consent forms as they are filed in the client's chart to ensure that all applicable information is documented. This will be overseen by the Operations Manager/Admissions Director and the Project Director. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
The facility failed to document the purpose of disclosure on the written, informed and voluntary consent from the client for the disclosure of information contained in the client record in five of seven client records reviewed on May 29 - 30, 2019.Consents for the client's primary care physician were completed during the intake process and did not include the purpose of disclosure.Client # 1 was admitted April 4, 2019.Client # 4 was admitted March 6, 2019 and discharged March 15, 2019. Client # 5 was admitted July 17, 2018 and discharged January 11, 2019. Client # 6 was admitted July 3, 2018 and discharged January 8, 2019. Client # 7 was admitted August 17, 2018 and discharged January 9, 2019.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager/Admissions Director confirms that the consents for the client's primary care physician did not include the purpose of disclosure. The Operations Manager/Admissions Director made immediate changes to the primary care physician consent to ensure that the purpose of disclosure is properly documented. The Operations Manager/Admissions Director will ensure that all applicable staff is re-trained as to the importance of clearly documenting the purpose of disclosure on all consents. This will be overseen by the Operations Manager/Admissions Director and the Project Director. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
The facility failed to document a copy of the consent was offered to the client in five of seven client records reviewed on May 29 - 30, 2019.Consents for the client's primary care physician were completed during the intake process. There was no documentation the client was offered a copy of these consents.Client # 1 was admitted April 4, 2019.Client # 4 was admitted March 6, 2019 and discharged March 15, 2019. Client # 5 was admitted July 17, 2018 and discharged January 11, 2019. Client # 6 was admitted July 3, 2018 and discharged January 8, 2019. Client # 7 was admitted August 17, 2018 and discharged January 9, 2019.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager/Admissions Director confirms that the consents for the client's primary care physician did not include documentation that the clients were offered a copy of these consents. The Operations Manager/Admissions Director made immediate changes to the primary care physician consent to ensure that they clearly document that the client is offered a copy of the consent, and whether or not they accept a copy. The Operations Manager/Admissions Director will ensure that all consents note that a client is offered a copy and whether or not they accept a copy. The Operations Manager/Admissions Director will ensure that all applicable staff is re-trained as to the importance of clearly documenting that a client is offered a copy, and whether or not they accept a copy of all consents. This will be overseen by the Project Director. |