INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Good Works Life Recovery House 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 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment in three of five personnel records.The findings include:Five personnel records were reviewed on January 7, 2016. Five personnel records were required to include documentation of fire extinguisher training upon staff employment. The facility failed to instruct all staff in the use of the fire extinguishers upon staff employment in personnel records # 3, 4 and 5.Employee # 3 was hired on November 23, 2015. Fire extinguisher training was not documented until December 8, 2015. The facility failed to instruct employee # 3 in the use of the fire extinguishers upon staff employment.Employee # 4 was hired on April 2, 2015. Fire extinguisher training was not documented until April 11, 2015. The facility failed to instruct employee # 4 in the use of the fire extinguishers upon staff employment.Employee # 5 was hired on May 18, 2015. Fire extinguisher training was not documented until August 9, 2015. The facility failed to instruct employee # 5 in the use of the fire extinguishers upon staff employment.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each personnel file has a checklist of things which need to be completed upon date of hire or first day of employment. The Administrative Assistant who is responsible for ensuring that fire extinguisher training is done within 7 days of hire, revised and added fire extinguisher training to this checklist.The list is used by the Administrative Assistant to ensure that all documents and trainings, such as First Aid/CPR, have occurred and are documented in each employee's personnel file. All new employee's receive this training via an internet website. The Administrative Assistant will ensure that this training becomes part of first day of employment orientation. She will document it on the personnel file checklist and ensure that the new employee completes a training evaluation form, indicating that the training was received and on what date. The Administrative Assistant will monitor personnel records on a monthly basis to ensure that the file is complete and accurate. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill records, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.The findings include:Fire drill records for January 2015 through December 2015 were reviewed on January 7, 2016. A fire drill during sleeping hours was due to be conducted at least every 6 months. The facility's sleeping hours are from 11:00 PM until 7:00 AM. The only fire drill during sleeping hours was conducted on August 20, 2015 at 11:55 PM. The facility failed to conduct a fire drill during sleeping hours at least every 6 months.The findings were reviewed with facility staff during the licensing process.This is a repeat citation from the January 12, 2015 inspection.
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Plan of Correction
The Administrative Assistant is responsible for overseeing that she and the support staff which she supervises are conducting the necessary fire drills. A new form was developed to document fire drills and it specifically indicates the need for two fire drills during sleep hours a minimum of every 6 months. The Administrative Assistant will train support staff on conducting fire drills and the use of the new form. |
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 document an informed and voluntary consent from the client that adhered to 4 Pa. Code 255.5 in six of seven client records.The findings include:Seven client records were reviewed on January 7, 2016. Seven client records were reviewed for written, informed and voluntary consents from the client that adhered to 4 Pa. Code 255.5. 4 Pa. Code 255.5 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.The facility failed to document an informed and voluntary consent from the client that adhered to 4 Pa. Code 255.5 in client records # 1, 2, 3, 4, 6 and 7.Client # 1 was admitted into treatment on November 3, 2015. A consent to release information was documented for the court magistrate on December 4, 2015. This consent listed the specific information to be released included the "results of assessment (significant medical, legal, employment, social)" for client # 1. This exceeds the limitations imposed at 4 Pa. Code 255.5.Client # 2 was admitted into treatment on July 27, 2015. A consent to release information was documented for the funding entity on July 27, 2015. This consent listed the specific information to be released included the "results of assessment (significant medical, legal, employment, social)" for client # 2. This exceeds the limitations imposed at 4 Pa. Code 255.5.Client # 3 was admitted into treatment on October 5, 2015. A consent to release information was documented for the funding entity on October 5, 2015. This consent listed the specific information to be released included the "results of assessment (significant medical, legal, employment, social)" for client # 3. This exceeds the limitations imposed at 4 Pa. Code 255.5.Client # 4 was admitted into treatment on August 18, 2015 and discharged on September 4, 2015. A consent to release information was documented for the funding entity on August 18, 2015. This consent listed the specific information to be released included the "results of assessment (significant medical, legal, employment, social)" for client # 4. This exceeds the limitations imposed at 4 Pa. Code 255.5.Client # 6 was admitted into treatment on July 6, 2015 and discharged on December 30, 2015. A consent to release information was documented for the funding entity on July 6, 2015. This consent listed the specific information to be released included the "results of assessment (significant medical, legal, employment, social)" for client # 6. This exceeds the limitations imposed at 4 Pa. Code 255.5.A consent to release information was documented for the court judge on August 3, 2015. This consent listed the specific information to be released included the "results of assessment (significant medical, legal, employment, social)" for client # 6. This exceeds the limitations imposed at 4 Pa. Code 255.5.Client # 7 was admitted into treatment on November 19, 2015 and discharged on December 7, 2015. A consent to release information was documented for the funding entity on November 19, 2015. This consent listed the specific information to be released included the "results of assessment (significant medical, legal, employment, social)" for client # 7. This exceeds the limitations imposed at 4 Pa. Code 255.5.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the problems identified with client consents, the Program Director made the decision that the Administrative Assistant will complete two client consents upon admission, for the client's pharmacy if they have one, and CRCSI, the mental health provider where they will be referred for a psych eval. All other consents will be completed by the client's counselor. The Program Director has revised the consents and trained the individuals responsible in how to complete them properly. All were made aware that information released needs to be restricted to what is specified in 4 Pa. Code 255.5 in order to avoid exceeding the limitations imposed for release of information. The Clinical Director will be responsible for monitoring consents and ensuring that only the information specified in 4 Pa. Code 255.5 is being released. The individual, support staff, that is responsible for filing in the client's records has also been trained on the accuracy of consents. Each time one is filed, she will review it for accuracy and return it to the person that completed it if a problem or mistake is found. She will also make the Clinical Director aware of the issue. The individual will receive further training and supervision from the Clinical Director. In addition, client records are audited monthly by a trained support staff and consents are a part of the audit. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
Based on a review of administrative materials, the facility failed to document a quarterly inspection of the medication storage area.The findings include:Administrative materials were reviewed on January 7, 2016. The facility was required to document quarterly inspections of the medication storage area. Quarterly inspections for 2015 were due to be completed no later than 3/31/15, 6/30/15, 9/30/15 and 12/31/15. The project/facility director confirmed no inspections of the medication storage area were documented for 2015.The findings were reviewed with facility staff.
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Plan of Correction
The Administrative Assistant developed a new form to ensure that quarterly inspections of the medication storage area are being performed and documented accurately. The new form reflects the policy in place that requires answering the five questions contained within LRH policy regarding medication inspections. The Administrative Assistant will take responsibility for ensuring that the inspections are being done timely and documented accurately. She will train the support staff person designated to perform this duty. |