INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 2, 2018 by staff from the Division of Accountability and Program Improvement. Based on the findings of the on-site inspection, Treatment Trends Inc.-Confront was found to be not 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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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant tour conducted on March 2, 2018 the facility allowed a space heater, that was not permanently mounted, in the director's office.This information was reviewed with thr facility staff during the investigation.
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Plan of Correction
Space heater was removed from the building by Treatment Trends Inc maintenance staff on March 3, 2018.
Staff will be reminded during the annual fire safety meeting (6/19 and 6/20/18) about space heaters not being permitted in the building. Office Administrator will check monthly while conducting the building checklist to ensure they are not in the building.
Treatment Trends Inc maintenance staff will install a wall mounted heater in the office by July 7, 2018.
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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant tour conducted on March 2, 2018 the facility failed to properly secure both hard-copy and electronic client records. The facility allowed client records and documents with client identifying information to be left on desks and file cabinet in the billing office in the rear of the facilty.Additionally, there were six cartons of client records sitting on the floor in the "bullpen" area on the first floor of the facility, directly in front of the billing office.The counselors' office at the rear of the building on the second floor had several client treatment plans, placed on top of a file cabinet, that had been filled out but were not properly secured.The staff computer in the office adjacent to the second-floor, front group room was unsecured and the screen displayed a document from a client record; the computer in a counselors' office at the rear of the building on the second floor had an unsecured computer which also displayed client information. This information was reviewed with thr facility staff during the investigation.
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Plan of Correction
1. All paperwork and boxes of records were immediately moved to the locked basement file room on March 2, 2018 by director and counselor.
2. Paperwork left out in counselor's room was immediately filed by counselor on March 2, 2018.
3. All computers in the building were set to "lock" after 5 minutes of no use and screensavers were enabled on March 3, 2018.
An email was sent to all staff about maintaining confidentiality with their paperwork, records, and computers on March 2, 2018. This email discussed locking all paperwork in file cabinets before leaving the office, logging off the computers, and locking the office doors. This was followed up in supervision sessions ongoing. This will also be followed up on at our annual Program Evaluation on May 31, 2018.
Program director and lead counselor periodically will walk around the building and check that rooms are locked, there are no charts/paperwork laying around, and computers are either off or locked.
A closing checklist was created for closing staff to sign off on checking that all rooms are locked at the end of the day. This was created and instituted on May 7, 2018. |