INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on January 7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Renewal Treatment, 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 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on the physical plant inspection, the facility failed to ensure the exits from the facility were unobstructed.
During the physical plant inspection, the exit door located behind the waiting room area was locked and could not be opened. The door will only unlock if the fire alarm is activited. The exit was obstructed from use in the event of any emergency that does not activate the alarm.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall ensure that all exits from the facility are unobstructed. Renewal Treatment, Inc. is deactivating the mag-lock that is on the exit door located behind the waiting room. The door will then open at all times and the exit will remain unobstructed. The VP HR and Compliance provided instruction to the maintenance staff on this requirement and they are making the necessary corrections to deactivate the mag-lock on the door. Once deactivated the mag-lock door will not be able to be locked. Continual compliance will be monitored during weekly and monthly safety and sanitation inspections of the facility performed by maintenance staff and maintenance supervisory staff. This plan of correction 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.
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Observations
Based on the review of client records, the facility failed to obtain informed and voluntary consent forms for the disclosure of information contained in the client record in six of seven client records.
The facility failed to obtain an informed and voluntary consent to release information in client records # 1, 2, 4, 5, 6 and 7.
Client records # 2, 5 and 6 documented a release for an organization that required the release be revoked in writing and several releases that required the release be revoked in writing or "verbally if necessary".
Client records 1, 4 and 7 documented several releases that required the release be revoked in writing or "verbally if necessary".
The consent to release information form states that revocation must be in writing. 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) 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." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall obtain informed and voluntary consent forms for the disclosure of information contained in the client records. Renewal Treatment, Inc. is changing our consent to release information form to include a statement that " consent to release information can be revoked at any time with notification from the client/consumer". The requirements for the consent revocation to be in writing or verbal shall be removed. The Clinical Director and Clinical Supervisor have provided instruction to the intake and Counselor staff on this requirement. The Clinical Supervisor shall ensure continual compliance via regular client record review. This plan of correction is in place. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of client records, the facility failed to update the treatment and rehabilitation plans at least every 60 days in six of seven client records.
Client # 2 had an update due on October 4 and December 4, 2020. There were no updates documented.
Client # 3 had an update due January 25, 2020. The update was completed on February 10, 2020.
Client # 4 had an update due on March 9, 2020. The update was completed on April 15, 2020.
Client # 5 had an update due on November 11, 2020. The update was completed on December 3, 2020.
Client # 6 had an update due on October 24,2020. The update was completed on November 2, 2020.
Client # 7 had an update due on November 14, 2020. The update was completed on November 25, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. staff shall update the treatment and rehabilitation plans at least every 60 days. The Clinical Supervisor provided training in regards to this requirement to the AOD Counselor staff. The AOD Counselors shall complete the treatment and rehabilitation plan updates at least every 60 days and if a client/consumer, is not available, the update will be completed without their presence and documented in the client/consumer's file. An additional treatment and rehabilitation plan update will be completed by the Counselor at the client/consumer's next session/appointment (when they are available) to participate, review and sign the document. Continual compliance shall be monitored by the Clinical Supervisor during regular chart review. The Clinical Supervisor shall have oversight responsibilities for this action plan. This plan of correction is in place. |