INITIAL COMMENTS
|
This report is a result of an on-site plan of correction follow-up inspection conducted on July 17, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Providence Living dba Providence Treatment 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:
|
Plan of Correction
|
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
|
Observations
Based on a review of four personnel records and the Department approved plan of correction for the February 9, 2023, annual licensing inspection, the facility failed to ensure that their Department approved plan of correction was followed. The plan of correction stated that the " facility director will require all staff persons including supporting staff to be CPR trained and maintained at this office location. " A review of CPR certification cards for staff demonstrated that the CPR certification for Employee # 3, a counselor, expired on May 31, 2023.
This is a repeat citation from the February 9, 2023 licensing inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 8/1/23, all clinicians and supporting staff person working at this office location are CPR trained including Employee #3.
The facility director will track CPR certifications and have staff renew their certifications prior to expiring by performing a quarterly audit. |
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.
|
Observations
Based on a review of client records and the Department approved plan of correction from the February 9, 2023 annual licensing inspection, the facility failed to ensure that consent to release information forms included the purpose of disclosure in nine of nine records reviewed. The Department approved plan of correction stated that the " updated form will be effective on 3/15/23 and resend to our active clients for signature. "
Client #1 was admitted on January 27, 2023 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on February 6, 2023 that was missing the purpose of the disclosure. The record contained no documentation that an updated consent to release information form was sent to or signed by the client.
Client #2 was admitted on June 2, 2022 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on June 2, 2022 that was missing the purpose of the disclosure. The record contained no documentation that an updated consent to release information form was sent to or signed by the client.
Client #3 was admitted on January 13, 2023 and was discharged on May 30, 2023. The record contained a consent to release information form to a regulatory agency signed by the client on February 2, 2023 that was missing the purpose of the disclosure. The record contained no documentation that an updated consent to release information form was sent to or signed by the client.
Client #4 was admitted on January 5, 2023 and was discharged on May 5, 2023. The record contained a consent to release information form to the funding source signed by the client on January 5, 2023 that was missing the purpose of the disclosure. The record contained no documentation that an updated consent to release information form was sent to or signed by the client.
Client #5 was admitted on June 6, 2022 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on June 6, 2022 that was missing the purpose of the disclosure. The record contained no documentation that an updated consent to release information form was sent to or signed by the client.
Client #6 was admitted on January 31, 2023 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on February 6, 2023 that was missing the purpose of the disclosure. The record contained no documentation that an updated consent to release information form was sent to or signed by the client.
Client #7 was admitted on December 27, 2022 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on December 27, 2022 that was missing the purpose of the disclosure. The record contained no documentation that an updated consent to release information form was sent to or signed by the client.
Client #8 was admitted on November 29, 2021 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on June 23, 2022 that was missing the purpose of the disclosure. The record contained no documentation that an updated consent to release information form was sent to or signed by the client.
Client #9 was admitted on June 3, 2022 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on March 15, 2023 that was missing the purpose of the disclosure.
This is a repeat citation from the February 9, 2023 licensing inspection.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of 8/1/23, Facility Director confirmed that client #1 to #9 re-signed our updated ROI form to the funding source.
Facility Director provided additional training to staff members on 7/28/23 on consent to release information form that includes the purpose of the disclosure to the funding source.
Facility Director/Supervisor will perform a random monthly audit to ensure the purpose of disclosure to the funding sources/insurers is listed and checked on the ROIs. |