INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 3, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lakeside NEPA 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
The backdoor opening into the parking area that maintenance uses was blocked by snow and could not be opened.
The door outside of the auditorium where AA meetings are held was blocked by snow and could not be opened.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 705.28 (a) (I) (i) Fire Safety to ensure stairways, hallways and exits are unobstructed. Facility contracted snow removal company to maintain and ensure all exits remain free and clear during inclement weather. The property will be monitored by the Health and Safety Officer regularly to maintain a reliable and safe work environment. All invoices of services rendered will be stored within the health and safety binder. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review on the facility ' s fire drill documentation, the facility failed to maintain a written fire drill record including the amount of time it took for evacuation, problems encountered and whether the fire alarm or smoke detector was operative.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
During the site inspection, the facility failed to comply with regulation 705.28 (d) (4) Fire Safety. The facility failed to maintain proper documentation of fire drill record. The facility implemented documentation to include specific information to be in compliance with regulations. The Health and Safety Officer will be trained on properly recording and ensure documentation is completed correctly on a monthly or as needed basis. All fire drills will be documented and securely stored within the Health and Safety binder. |
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.
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Observations
Based on a review on the facility ' s fire drill record, the facility failed to set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 705.28 (d) (7) Fire Safety setting off fire alarm or smoke detector during each fire drill. The Health and Safety Officer will be trained on the proper protocol when conducting monthly fire drills. Communication with the alarm company to ensure they are aware when fire drills are conducted. All fire drills will be documented and securely stored within the Health and Safety binder. |
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 seven client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the record to the client ' s funding source in all seven records reviewed. The project ' s clinical director confirmed the funding sources are being billed and no informed and voluntary consent from the client was obtained.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 709.28 (c) Confidentiality to maintain consent for disclosure of information contained in the record to the clients funding source. The Clinical Director trained staff on the importance of properly documenting and completing consent releases to ensure and protect client confidentiality. The Clinical Director will monitor and review charts to ensure releases are documented and completed properly. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of seven client records, the project failed to document written acknowledgement by clients that they have been notified of their right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. The project ' s policy included this information, however what was presented to the client for acknowledgement did not.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 709.30 (3) Client Rights to inspect their own records. The Clinical Director will provide an in-house training with the clinical staff to inform clients of their right to inspect their own record. Clients will be informed of their rights and sign documentation of acknowledgement. The Clinical Director is responsible at ensuring all clinical charts maintain in compliance during audits. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of seven client records, the project failed to document written acknowledgement by clients that they have been notified of their right to inspect their own records. Clients have the right to appeal a decision limiting access to their records to the director. The project ' s policy included this information, however what was presented to the client for acknowledgement did not.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The facility failed to comply with 709.30 (4) Client Rights to inspect and right to appeal a decision limiting access to their records. The Clinical Director will provide in-house training with clinical team members to review with clients their rights at deciding limitation of access. Clients will be informed of their rights and sign documentation of acknowledgement. The Clinical Director is responsible at ensuring all clinical charts maintain in compliance during audits. |
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 a review of seven client records, the project failed to document written acknowledgement by clients that they have been notified of their right to inspect their own records. Clients have the right to submit rebuttal data or memoranda to their own records. The project ' s policy included this information, however what was presented to the client for acknowledgement did not.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The facility failed to comply with 709.30 (6) Client Rights to inspect and submit rebuttal data or memoranda to their own record. The Clinical Director will provide in-house training with clinical team members to review with clients their rights at submitting rebuttal or memoranda to their record. Clients will be informed of their rights and sign documentation of acknowledgement. The Clinical Director is responsible at ensuring all clinical charts maintain in compliance during audits. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of seven client records, the project failed to notify three clients, in writing, of a decision to involuntarily terminate their treatment at the project. The notice shall include the reason for termination.
Client #5 was admitted on August 18, 20 and discharged on November 30, 2020. The client record did not contain documentation in writing, of a decision to involuntarily terminate their treatment at the project. Nor did it include the reason for termination.
Client #6 was admitted on November 17, 2020 and discharged on December 11, 2020. The client record did not contain documentation in writing, of a decision to involuntarily terminate their treatment at the project. Nor did it include the reason for termination.
Client #7 was admitted on July 28, 2020 and discharged on January 5, 2021. The client record did not contain documentation in writing, of a decision to involuntarily terminate their treatment at the project. Nor did it include the reason for termination.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The facility did not comply with regulation 709.33 (a) Notification of Termination. No written notification was sent to the client's home of the decision of involuntarily terminate. The Clinical Supervisor will implement a formal involuntary termination letter that will be reviewed by clinical team. This letter will be uploaded to the client's electronic medical record and mailed to their home. The notification will include the date and reason for termination. It is the responsibility of the Clinical Director to ensure clinical team completes and uploads the notification. Once completed, the Clinical Director will mail the notification to the client's home. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the facility failed to develop individual treatment and rehabilitation plan with a client that includes written documentation of type and frequency of treatment and rehabilitation services in five records reviewed.
Client #1 was admitted on June 19, 2020 and was still current at the time of the inspection. Individual treatment and rehabilitation plans dated June 29, 2020, August 13, 2020 and October 5, 2020 did not include the type of treatment and rehabilitation services.
Client #2 was admitted on December 3, 2020 and was still current at the time of the inspection. An individual treatment and rehabilitation plan dated January 7, 2021 did not include the type and frequency of treatment and rehabilitation services.
Client #3 was admitted on November 19, 2020 and was still current at the time of the inspection. Individual treatment and rehabilitation plans dated November 25, 2020 and January 25, 2021 did not include the type and frequency of treatment and rehabilitation services.
Client #4 was admitted on August 11, 2020 and was still current at the time of the inspection. Individual treatment and rehabilitation plans dated August 18, 2020, October 18, 2020, November 18, 2020, December 18, 2020, and January 18, 2021 did not include the type and frequency of treatment and rehabilitation services.
Client #5 was admitted on August 18, 2020 and was discharged on November 30, 2020. Individual treatment and rehabilitation plans dated August 21, 2020 and November 6, 2020 did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 709.92 (a)(2) Treatment and Rehabilitation Services with the frequency of treatment and rehabilitation services. The Clinical Director will train all clinical staff members to include the frequency of treatment and rehabilitation services in order to ensure plans are developed within a timely manner and in compliance with this regulation. The Clinical Director will monitor and review all charts to ensure clinical staff members are properly documenting and completing services on specific due dates. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of seven client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in one record.
Client #5 was admitted on August 18, 2020 and was discharged on November 30, 2020. A treatment and rehabilitation plan was dated August 21, 2020 and should have been updated by October 21, 2020. The next treatment and rehabilitation plan update was not until November 6, 2020.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
The facility failed to comply with regulation 709.92(b) Treatment and Rehabilitation to review and update plans at least every 60 days in one record. In order to ensure an individual and rehabilitation plan is developed within a timely manner, all clinical staff members will be trained by the Clinical Director on the proper time frame for completing and updating plans. All assigned clinical staff members will complete all documentation within the specific time frame to remain in compliance with regulation. The Clinical Director will review and monitor charts during audits to ensure all plans are completed and updated on-time. |