INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 30, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sojourner House, 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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709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on consents to release information in two of seven client records.
Client #1 was admitted to treatment on November 23, 2021 and is a current client. Client #1 signed two consents to release information on December 3, 2021 that did not include the purpose of the disclosure.
Client #6 was admitted to treatment on May 5, 2021 and discharged on November 15, 2021. Client #6 signed three consents to release information on July 1, 2021 and one consent to release information on November 15, 2021 that did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and process has been adjusted effective 04/05/22.
*The staff training and corrective actions from our non-compliance includes a list of trainings for new hires as they work with their associated managers, and discuss in supervision for job associated required trainings, and paperwork.
The Purpose of consents is to be signed out appropriately by staff and consumer. The purpose of consents will be audited by supervisors via chart audit, in it's entirety.
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709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of the witness on consents to release information in one of seven client records.
Client #6 was admitted to treatment on May 5, 2021 and discharged on November 15, 2021. Client #6 signed three consents to release information on July 1, 2021 that did not include a dated witness signature.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The protocol to address missing signatures, in consumer(client) files is to audit random files weekly and in supervision. this is to address missing witness and consumer signatures along with dates of admission, discharge, purpose and any follow-up.
During weekly treatment team and supervision, the clinical supervisor will randomly audit files and folders to ensure the client has signed all applicable releases, and that the therapist completes all forms fully;
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709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of the consent was offered to the client in one of seven client records.
Client #6 was admitted to treatment on May 5, 2021 and discharged on November 15, 2021. Client #6 signed three consents to release information on July 1, 2021 that did not include documentation a copy of the consent was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
to address concerns of consumers(clients) proof the form(s) were offered, a line has been added on all releases where a client/consumer can accept or reject the documentation as well as a witness signature, along with date and purpose of consent/release.
This follow-up will be documented in treatment team, and in supervision to discuss the needs of the consumers, files, releases and all applicable paperwork.
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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 the review of seven of seven client records, the facility failed to document written acknowledgement the client was informed of the right that no client may be deprived of a civil right solely by reason of treatment.
This required client right was not documented in the materials provided to the client.
These findings were reviewed with facility staff during the licensing process.
This is a repeat deficiency from the March 18, 2021 annual licensing inspection.
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Plan of Correction
All DDAP requirements were updated this includes the consumers bill of rights which are located in every file, along with a signature.
When reviewing and auditing charts and files, the client bill of rights will be reviewed in its entirety in supervision, and treatment team meetings.
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709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of seven of seven client records, the facility failed to document written acknowledgement that the client was informed of the right to submit rebuttal data or memoranda to their own records.
This client right was not documented in the materials provided to clients.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the March 18, 2021 annual licensing inspection.
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Plan of Correction
The agency executive director drafted a memo to address concerns of clients rights, grievances, and concerns. The subject memorandum was drafted on April 18, 2022 and forwarded to all staff. The memorandum is placed in the client file folders effective 4/18/22, at any and all incoming intakes.
The client rights have been documented per DDAP requirements.
There will be chart and file audits randomly performed by the clinical supervisor during supervision, and treatment team meetings.
The clinical and program supervisor will make certain all current clients, and staff have a printed copy.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative documentation, the facility failed to document inspections of the medication storage area at least quarterly.
There was no documentation of medication storage inspections for the time period of March 2021 - March 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The plan and new policy of medication storage inspections for the time period of March 2021-March 2022 are not documented.
to address the policy of procedures of medications storage, and inspections. the protocol is to audit the storage of medications monthly, with documentations of the date, signature of employee that performed the medication storage inspection log, along with a copy to be documented in the shift reports of the agency. the subject procedure shall begin on 4/19/22. this is the responsibility of the operations supervisor and medication officer to monitor.
Policy &Procedure: Medication 709.32
Revised Date: 4/19/2022
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up contact, as per agency policy of seven days post discharge, in three of four client records.
Client #4 was admitted on June 21, 2021 and discharged on January 19, 2022. The follow up contact was due to be completed by January 26, 2022. There was no follow up contact documented in client record #4.
Client #5 was admitted on April 8, 2021 and discharged on October 8, 2021. The follow up contact was due to be completed by October 15, 2021. There was no follow up contact documented in client record #5.
Client #6 was admitted on May 5, 2021 and discharged on November 15, 2021. The follow up contact was due to be completed by November 22, 2021. There was no follow up contact documented in client record #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RE: Quality Control regarding all documentations not limited to releases, discharge follow-up, and any and all client record/form submissions for Client #4, Client #5, and Client #6.
To address concerns of missing signatures upon discharge with clients(consumers). all files along with discharge paperwork for follow-up will be audited by the clinical supervisor at random, the clinical staff will document follow-up with the date, purpose of follow-up, witness, and signatures. The clinical staff is aware if the consumer is no longer available with the information they left at discharge to document with the name and date, reason.
additionally during weekly treatment team meetings files are audited at random. follow-ups calls, email, or both are due within seven(7) business days and placed in the file of the client(consumer). |