INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 23, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care Center 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 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on observation during a physical plant inspection, the facility failed to light interior exits and stairs at all times.The findings include:A physical plant inspection was conducted with the facility director and clinical supervisor on April 23, 2015 at approximately 2:00 PM. The facility's rear emergency exit door is located at the bottom of a stairwell. The ceiling light located in this stairwell near the emergency exit door was not operative. The facility failed to light interior exits and stairs at all times.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will contact the landlord of the facility and request that the down stairs light be fixed. The light will be fixed by 6/15/15. The supervisor will continue to do random checks of exits and make sure appropriate lighting is in place. |
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 a written, informed and voluntary consent from the client prior to the disclosure of information contained in the client record in five of ten client records.The findings include:Ten client records were reviewed on April 23, 2015. Ten client records were required to include documentation of written, informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client prior to disclosing information contained in the client record to a funding entity in client records # 2, 3, 4, 6 and 7.Client # 2 was admitted into treatment on January 2, 2015. The facility failed to obtain a written, informed and voluntary consent from client # 2 prior to disclosing information contained in the client record to a funding entity.Client # 3 was admitted into treatment on December 11, 2014. The facility failed to obtain a written, informed and voluntary consent from client # 3 prior to disclosing information contained in the client record to a funding entity.Client # 4 was admitted into treatment on February 27, 2015. The facility failed to obtain a written, informed and voluntary consent from client # 4 prior to disclosing information contained in the client record to a funding entity. Client record # 4 contained a written consent that indicated the purpose of the release was "funding". This consent to release information form did not include the name of the funding entity.Client # 6 was admitted into treatment on July 29, 2014 and discharged on September 8, 2014. The facility failed to obtain a written, informed and voluntary consent from client # 6 prior to disclosing information contained in the client record to a funding entity.Client # 7 was admitted into treatment on June 3, 2014 and discharged on January 19, 2015. The facility failed to obtain a written, informed and voluntary consent from client # 7 prior to disclosing information contained in the client record to a funding entity.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will obtain appropriate Consents to Release Information for clients #2,3,4,5 and 7 will develop and provide a training update of the accurate and appropriate completion of consents to release information by May 30th, 2015 Information to be covered will include appropriate type of release, the appropriate release for funding sources, appropriate choice of information to be released; and limitations of 4 Pa. code subsection 255.5, at a minimum. Consents/Releases will be completed every time an individual's insurance changes at the time of the change. This will be completed by May 30th, 2015. Clinical Supervisor will continue to review and monitor consents and releases through internal chart reviews and supervision. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the facility failed to demonstrate efforts toward informing clients of the rights specified in 709.30 (1 - 6) in two of ten client records.The findings include:Ten client records were reviewed on April 23, 2015. The facility was required to demonstrate the ten clients were informed of the rights specified in 709.30 (1 - 6). The facility failed to demonstrate efforts toward informing clients of the rights specified in 709.30 (1 - 6) in client records # 1 and 3.Client # 1 was admitted into treatment on October 2, 2014. The facility failed to demonstrate efforts toward informing client # 1 of the rights specified in 709.30 (1 - 6) , as of April 23, 2015.Client # 3 was admitted into treatment on December 11, 2014. The facility failed to demonstrate efforts toward informing client # 3 of the rights specified in 709.30 (1 - 6) , as of April 23, 2015.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review regulations and guidelines regarding informing our clients of client rights by the clinical supervisor. This will occur no later than 5/30/15. In addition, staff members who were responsible for charts # 1 and 3 will obtain documentation of receiving information regarding their client rights for those clients where it is appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. |
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on a review of client records, the facility failed to document a consent to treatment in two of ten client records.The findings include:Ten client records were reviewed on April 23, 2015. Ten client records required documentation of a consent to treatment. The facility failed to document a consent to treatment in client records # 1 and 3.Client # 1 was admitted into treatment on October 2, 2014. The intake process was completed on October 2, 2014. The facility failed to document a consent to treatment in client record # 1, as of April 23, 2015.Client # 3 was admitted into treatment on December 11, 2014. The intake process was completed on December 11, 2014. The facility failed to document a consent to treatment in client record # 3, as of April 23, 2015.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review the policy and procedure of obtaining consent for treatment by the clinical supervisor. This will occur no later than 5/30/15. In addition, staff members who were responsible for charts 1 and 3 will obtain consent for treatment for those clients where it is appropriate. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. |