INITIAL COMMENTS
|
This report is the result of an on-site licensure renewal inspection conducted on February 14, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Roxbury 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:
|
Plan of Correction
|
705.27 (4) (i) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(i) The evacuation and transfer of clients and staff to a safe location.
|
Observations
Based on the review of policy and procedures, the facility failed to have a procedure for the evacuation of staff and clients during an emergency.
The findings included:
An administrative review occurred on February 7, 2012. The procedures for emergencies was reviewed. The facility did not have a site specific procedure for evacuation.
The Facility Director confirmed that they have no additional procedure policies.
|
Plan of Correction
The facility is currently revising agency policy. The revision will reflect a site-specific procedure for the evacuation of staff and clients during an emergency. The revised policy will be completed on or before 3/31/12 and will become part of the general safety & emergency policies and procedures. The Director of Outpatient Services will assume primary responsibility for this task and will monitor that it does not reoccur once it becomes part of the applicable policies and procedures. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a physical plant inspection, the facility failed to set off a fire alarm or smoke detector during fire drills.
The findings include:
On February 14, 2012 at approximately 11 a.m., during the physical plant inspection, a review of the fire safety was conducted. The facility does not set off a fire alarm or smoke detector during fire drills. The facility uses a sign shown to staff members at the time of the fire drill.
During an interview with the Facility Director, they described the process used for the drills.
|
Plan of Correction
The facility intends to purchase an air horn to be sounded during monthly fire drills. This will be completed by March 21, 2012.
The Director of Outpatient Services will assume primary responsibility for this task and will monitor its implementation and ongoing practice.
|
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
|
Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24-hour emergency medical coverage.
The findings include:
An administrative review occurred on February 7, 2012. The letters of agreement were reviewed at that time. No letter of agreement regarding 24-hour emergency medical coverage was documented.
The Facility Director confirmed that they have no additional letters of agreement.
|
Plan of Correction
The Risk Manager has obtained a letter of agreement with Waynesboro Hospital for 24-hour emergency medical coverage. This was completed on February 27, 2012.
The Risk Manager will perform annual reviews of referral agreements and will report findings annually to the Medical Executive Committee.
|
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:
|
Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information was obtained in three of four client records.
The findings included:
Eight client records were reviewed on February 14, 2012. Four of the client records reviewed required consent to release information. The facility failed to ensure that an informed and voluntary consent to release information was obtained in three records, # 5, 6, and 7.
A review of client record # 5 revealed information was released to a funding source without a documented consent on 4/2/2011 and 9/15/2011.
A review of client record # 6 revealed information was released to a funding source without a documented consent on 10/26/2011.
A review of client record # 7 revealed information was released to a funding source without a documented consent on 10/19/2011.
The findings were reviewed with the Facility Director and not disputed.
|
Plan of Correction
A consent to release information to the Pennsylvania Department of Public Welfare PROMISE Internet has been developed and said documentation will be routinely obtained for all clients for whom recipient eligibility verification is done electronically.
Staff have been notified as to the necessity of obtaining a Pennsylvania Department of Public Welfare consent, procedures have been modified, and the Director of OP Services will monitor records on a monthly basis to ensure the new consent is being used. This was completed on March 2, 2012.
|
709.28(c)(6) 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:
(6) Expiration date of the consent.
|
Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information included an expiration date in one of four records.
The findings included:
Eight client records were reviewed on February 14, 2012. Four of the client records reviewed required consent to release information. The facility failed to ensure that an expiration date was completed on a consent to release information in one record, # 5.
A review of client record # 5 revealed a consent to release information was obtained on 8/26/2011. The client signed the release at a different location with the faxed copy being sent to the facility. After receipt of the fax, the facility completed the expiration date and documented the client having rejected a copy.
The findings were reviewed with the Facility Director and not disputed.
|
Plan of Correction
Staff received a training on 2/29/12 on the importance of viewing the consent to release as a legal document.
The necessity of filling in all elements of a consent to release information (including the expiration date and determining whether the client accepts or rejects a copy) prior to obtaining the client's signature on the consent was clarified and reinforced.
The Director of OP Services will monitor records to ensure adherence by all staff to the rules regarding proper completion of consents to release information. Corrective action will occur as needed.
|
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:
|
Observations
Based on a review of facility policy, a review of the client handbook, and a physical plant inspection, the facility failed to inform clients of their rights.
The findings include:
An administrative review of the facility's policy was completed on February 6, 2012. The facility's policy states clients will be informed of their rights via the Patient Bill of Rights, and displayed in the waiting room, lobby area and other areas frequented by persons receiving services.
On February 14, 2012 at approximately 11 a.m., during the physical plant inspection, a review of the posted information was completed. The facility did not display the patient rights.
On February 14, 2012, the client handbook was reviewed. The handbook did not include the Patient Bill of Rights.
The Facility Director was presented the findings. The findings were not disputed.
|
Plan of Correction
The Director of OP Services has revised the patient handbook to include a copy of the patient's Bill of Rights. The patient's Bill of Rights has also been posted in the public areas of the outpatient offices. The revision and public posting was completed on 2/23/12.
The Risk Manager will review Patient Handbooks annually and will monitor and update Handbooks as needed when changes are required.
|
709.91(b)(4) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
|
Observations
Based on the review of client records, the facility failed to ensure a consent to treatment was completed in one of four records.
The findings included:
Eight client records were reviewed on February 14, 2012. Four of the client records reviewed required consent to treatment. The facility failed to ensure that a consent to treatment was completed in one record, # 5.
Client # 5 was admitted on 10/26/2011. A review of documentation revealed a consent to treatment completed on 4/7/2011. A consent to treatment was not completed upon admission of the client.
|
Plan of Correction
The Director of OP Services will facilitate a training with clinical staff re-educating them on the expectations and procedures on documentation for clients who are re-admitted and return to treatment following a previous episode of care.
This will be completed by March 31, 2012.
New consents to treatment must be obtained for each episode of care at the time of the intake appointment.
The Director of OP Services will monitor records to ensure full compliance with this expectation. Corrective action will occur as needed for any deviation from this expectation.
|
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on the review of client records, the facility failed to ensure a psychosocial evaluation was completed in one of four records.
The findings included:
Eight client records were reviewed on February 14, 2012. Four of the client records reviewed required a psychosocial evaluation. The facility failed to ensure that a psychosocial evaluation was completed in record # 6.
Client # 6 was admitted on 11/1/2011. A review of documentation revealed a psychosocial evaluation completed on 3/24/2011. This evaluation was updated 11/9/2011. This update was seven months after the evaluation and did not include the required content.
|
Plan of Correction
The Director of OP Services will facilitate a training with clinical staff re-educating them on the expectations and procedures on documentation for clients who are re-admitted and return to treatment following a previous episode of care. This will be completed by March 31, 2012.
Each time a client returns to treatment, a new psychosocial evaluation must be undertaken. An update notation to a prior psychosocial evaluation is considered insufficient.
The Director of OP Services will monitor records to ensure full compliance with this expectation. Corrective action will occur as needed for any deviation from this expectation.
|
709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
|
Observations
Based on a review of administrative documentation, the facility failed to comply with 55 Pa. Code Part III.
The findings included:
Administrative documentation did not include a physician on staff to provide oversite for the management of Medical Assistance funded clients.
The findings were reviewed and confirmed by the Facility Director.
|
Plan of Correction
The facility is committed to correct this deficiency and is currently in the process of recruiting a physician to provide oversight as required by 55 Pa. Code Part III.
The Project Director has completed interviews and a candidate has tentatively accepted the position. A start date is undetermined pending a signed contract; however the deficiency should be resolved on or before April 15, 2012.
It is the responsibility of the Chief Medical Officer to monitor the assigned physicians and fulfillment of their duties within the facility to ensure the deficiency does not recur.
|