INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 2015 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, RHD / New Start II 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 an unannounced fire drill at least once a month.
The findings include:
A review of the May 2014 through May 2015 fire drill logs was conducted on June 25, 2015. There was no documentation that an unannounced fire drill was conducted for the month of February 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By July 1,2015 Director will create a monthly fire drill schedule. Director will ensure an unannounced fire drill is conducted and documented every month. Director will meet with staff through supervision and ensure documentation is completed and filed in fire drill log. Director will monitor for on-going compliance. |
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 keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in eleven of eleven records reviewed.
The findings included:
4 Pa. Code states:
Information released to judges, probation or parole officers, insurance company, health or hospital plan or governmental officials, pursuant to paragraphs (1), (2), (4),(7), (8) or subsection (a) of this section, is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following.
(1) Whether the client is or is not in treatment.
(2) Client's prognosis.
(3) The nature of the project.
(4) A brief description of the client's progress.
(5) A short statement as to whether the client has relapsed into drug or alcohol abuse and the frequency of such relapse.
Eleven client records requiring proper releases of information were reviewed on June 25, 2015. The facility failed to stay within the limits imposed by 4 Pa. Code 255.5 (b) in client records, # 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, and 11.
Client #1 was admitted into treatment on November 5, 2014 and was still an active client at time of the inspection. A release of information to a government agency was signed on 11/5/14 and allowed for the disclosure of the client's monthly expenses and financial obligations, which exceeded 255.5.
Client #2 was admitted into treatment on February 4, 2015 and was still an active client at time of the inspection. A release of information to a government agency was signed on 2/4/15 and allowed for the disclosure of the client's monthly expenses and financial obligations, which exceeded 255.5.
Client #3 was admitted into treatment on March 24, 2015 and was still an active client at time of the inspection. A release of information to a government agency was signed on 3/24/15 and allowed for the disclosure of the client's monthly expenses and financial obligations, which exceeded 255.5.
Client #4 was admitted into treatment on April 13, 2015 and was still an active client at time of the inspection. A release of information to a government agency was signed on 4/16/15 and allowed for the disclosure of the client's monthly expenses and financial obligations, which exceeded 255.5.
Client #5 was admitted into treatment on July 31, 2014 and was discharged on November 17, 2014. A release of information to a government agency was signed on 7/31/14 and allowed for the disclosure of the client's monthly expenses and financial obligations, which exceeded 255.5.
Client #6 was admitted into treatment on August 12, 2014 and was discharged on February 20, 2015. A release of information to a government agency was signed on 8/12/14 and allowed for the disclosure of the client's monthly expenses and financial obligations, which exceeded 255.5.
Client #7 was admitted into treatment on March 5, 2015 and was discharged on May 6, 2015. A release of information to a government agency was signed on 3/5/15 and allowed for the disclosure of the client's monthly expenses and financial obligations, which exceeded 255.5.
Client #8 was admitted into treatment on April 17, 2014 and was discharged on March 3, 2015. A release of information to a government agency was signed on 4/17/14 and allowed for the disclosure of the client's monthly expenses and financial obligations, which exceeded 255.5.
Client #9 was admitted into treatment on September 2, 2014 and was discharged on March 31, 2015. A release of information to a government agency was signed on 9/2/14 and allowed for the disclosure of the client's monthly expenses and financial obligations, which exceeded 255.5.
Client #10 was admitted into treatment on December 2, 2014 and was discharged on April 1, 2015. A release of information to a government agency was signed on 12/2/14 and allowed for the disclosure of the client's monthly expenses and financial obligations, which exceeded 255.5.
Client #11 was admitted into treatment on May 6, 2014 and was discharged on May 11, 2015. A release of information to a government agency was signed on 5/6/14 and allowed for the disclosure of the client's monthly expenses and financial obligations, which exceeded 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By July 25,2015 Director will facilitate a training with all staff to ensure that the facility keep disclosures of client identifying information within the limits established by 4 Pa.Code 255.5. Director will monitor through supervision and program oversight for on-going compliance.
By 7/22/15 consents for clients #2 and #3 will be re-written with Therapist and reviewed by Director. Clients #1,4,5,6,7,8,9,10 and 11 are all discharged charts. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document physical examinations during the intake process in four of eleven client records reviewed.
The findings include:
Eleven client records requiring documentation of physical examinations were reviewed on June 25, 2015. The facility failed to complete physical examinations as part of the intake process in client records # 3, 4, 5, and 8.
Client #3 was admitted into treatment on March 24, 2015 and was still an active client as of the date of the on-site inspection. There was documentation of the client's physical examination in the client record; however, the physical examination was completed on 6/11/15, which was after the intake process.
Client #4 was admitted into treatment on April 13, 2015 and was still an active client as of the date of the on-site inspection. There was documentation of the client's physical examination in the client record; however, the physical examination was completed on 5/25/15, which was after the intake process.
Client #5 was admitted into treatment on July 31, 2014 and was discharged on November 17, 2014. There was no physical examination documented in the client record as of the date of this inspection.
Client #8 was admitted into treatment on April 17, 2014 and was discharged on March 3, 2015. There was no physical examination documented in the client record as of the date of this inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/15/2015 Director met with staff in supervision to ensure the program has documented physical examinations for all clients during the intake process. Director will monitor for on-going compliance through supervision and program oversight. Client #3 was admitted on 3/24/2015 and had a physical on 6/11/15. Client #4 was admitted on 4/13/15 and had a physical on 5/25/15. Clients #5 and #8 are discharged from the facility. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in four of eleven client records reviewed.
The findings include:
Eleven client records requiring the treatment and rehabilitation plans to be reviewed and updated at least every 30 days were reviewed on June 25, 2015. The facility failed to document 30-day updated treatment and rehabilitation plans in client records # 4, 5, 6, 10.
Client #4 was admitted into treatment on April 13, 2015 and was still an active client as of the date of the on-site inspection. The treatment and rehabilitation plan was developed on 4/13/15 and there should have been an update no later than 5/13/15; however, the only treatment and rehabilitation plan update, dated 6/9/15, documented in the record as of the date of the inspection.
Client #5 was admitted into treatment on July 31, 2014 and was discharged on November 17, 2014. The last documented treatment and rehabilitation plan update was developed on 9/30/14 and there should have been an update no later than 10/30/14; however, there was no treatment and rehabilitation plan update documented in the record as of the date of the inspection.
Client #6 was admitted into treatment on August 12, 2014 and was discharged on February 20, 2015. The last documented treatment and rehabilitation plan update was developed on 1/06/15 and there should have been an update no later than 2/06/15; however, there was no treatment and rehabilitation plan update documented in the record as of the date of the inspection.
Client #10 was admitted into treatment on December 2, 2014 and was discharged on April 1, 2015. The client's documented comprehensive treatment and rehabilitation plan was developed on 1/1/15 and there should have been an update no later than 2/1/15; however, the treatment and rehabilitation plan update documented in the record was completed on 3/17/15.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with the clinical team in supervision on 7/6/15 to review completing treatment plans every 30 days. Director will ensure all treatment and rehabilitation plans are reviewed and updated at least every 30 days. Director will monitor through chart review and supervision for on- going compliance. Client #4 was active at the time of inspection, but has since discharged. Clients #5,6 and 10 are discharged clients. |