INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 2017 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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705.7 (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
Based on a physical plant inspection on July 20, 2017 at approximately 11:00 A.M., the temperature of the facility's refrigerator, located in the group room/lounge area, was measured at 54 degrees.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to maintain proper food safety and appropriate refrigerator temperature in the facility the program will train all staff on the correct way to record and log temperatures for review. Furthermore the refrigerator in question will not be used until it is repaired and operating at the appropriate temperature. Facility staff will request an immediate maintenance repair 7/21/2017 to address the problem. The expectation is that the refrigerator will be fixed and operating by 8/1/17. The Director and Assistance Director will review all reports weekly to ensure the refrigerator is readings are 40 or below. The program Office Manager will schedule semi-annual inspections, and schedule repairs as needed. |
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 a review of 7 client records, the facility failed to document a complete, informed and voluntary consent to release information form prior to the disclosure of information in two records. Additionally, there were consent to release information forms missing required information in two records. Also, the facility failed to keep disclosures of patient identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in two records.
Client # 1 was admitted on 2/1/17 and was discharged on 3/16/17. The record contained documentation to be completed by another treatment provider which disclosed the client's presence in treatment, for whom there was no signed consent to release information form in the client record.
Client # 2 was admitted on 1/3/17 and was discharged on 6/12/16. The record contained a consent to release information form to a family member signed on 1/4/17, which did not include the information to be disclosed or the purpose of the disclosure. The record also contained documentation to be completed by another treatment provider which disclosed the client's presence in treatment, for whom there was no signed consent to release information form in the client record. Additionally, there was documentation of correspondence with the funding source on 3/22/17 and 3/23/17, which disclosed the client's psychiatric evaluation and specific psychotropic medications, respectively, which exceeded the limits established by 4 Pa Code 255.5 (b).
Client # 5 was admitted on 5/31/17 and was an active client at the time of inspection. The record contained documentation of correspondence with the funding source on 7/14/17, which disclosed the client's specific drug of choice, and the amount, the frequency, and the date of last use, which exceeded the limits established by 4 Pa Code 255.5 (b). Additionally, the record contained documentation of correspondence with another treatment provider on 7/19/17, for whom there was no signed consent form in the client record.
Client # 6 was admitted on 5/31/17 and was an active client at the time of inspection. The record contained two consent to release information forms, both signed on 5/31/17, which did not include the name, agency, or organization to whom the disclosure would be made to, the specific information to be disclosed, and the purpose of the disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By August 05, 2017 the Program Director will train all staff on proper procedures when completing informed voluntary consent forms. During training, Program Director will cover in detail all sections including writing out what outside agency/person consent is for, specific information that consent will cover and checking off appropriate boxes when identifying the purpose of the disclosure. The training will also cover the appropriate length of each consent (not exceeding 1 year) and having client's and witness' signature on each consent. Lastly, staff will be educated on the limitations regarding information documented in charts in correspondence to funding source.
Charts will be review monthly by both Clinical Supervisor and Program Director to ensure that consents are being completed correctly and in their entirety.
By 8/5/ 2017 Program Director will meet with clients #5 & 6 to complete consents in their entirety. Program Director will document the purpose of the disclosures and identify and check appropriate box for the specific information to be released on consents.
Program Director will also review all open charts to ensure that each disclosure consents are completed correctly and in their entirety.
In the event that any consent is not completed correctly, Program Director will meet with the respective client to complete consent and then meet with staff member to go over consent and discuss reason(s) consent was not correct.
Clients #1 & 2 is discharged chart.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to include that the facility does not discriminate in the provision of services based on marital status, ethnicity, and sexual orientation on the client right's written acknowledgement form that the clients signed in all 7 client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New Start II Program Intake Packet, specifically the Civil Rights Compliance form, will be updated by the program, with RHD final approval, to include documentation that RHD New Start II does not discriminate in the provision of services based on marital status, ethnicity and sexual orientation. Program Director will ensure that updated, revised Civil Rights Compliance forms are implemented once they are approved by RHD on 8/14/2017. New admissions beginning on 8/14/2017 will sign the updated and RHD approved Civil Rights Compliance Form as part of the intake process. Current clients will review and sign the updated RHD approved Civil Right Compliance Form on 8/15/2017."
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the facility's unusual incident reports on July 20, 2017, the facility failed to notify the Department within the regulatory timeframe following the unusual incidents below, which were discovered during the licensing process.
The incident dates and incident reason are:
August 11, 2016 - Ambulance presence onsite
February 1, 2017 - Physical assault by client
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By August 14, 2017 Program Director will train all staff on policy for reporting unusual incidents that require police, ambulance, fire, and physical assault or sexual assault onsite. Staff will be taught procedure on informing DDAP of such incidents and provided the fax number to ensure that incidents are faxed to DDAP within 3 days. The Program Director will review all incident reports and monitor on-going compliance through supervision and monthly staff meeting. In addition the two unusual incident reports identified during the inspection will be completed and sent to DDAP by 8/14/17 |