INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and methadone monitoring conducted on June 23, 2021 through June 24, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Consortium 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to have hot water under pressure in all facility bathrooms. On June 24, 2021, at approximately 10:00 AM, there was no running hot water in the men's bathroom, which is located on the second floor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 7/6/21 Facility Manager will have repaired the hot running water in the second floor men's bathroom.
By 7/6/21 Facility Manager will begin weekly walkthroughs of the facility to ensure hot water is working appropriately. |
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 client records, the facility failed to obtain an informed and voluntary consent for the disclosure of information contained in the client record in two of seven client records reviewed.
Client #5 was admitted on May 8, 2014 and was discharged May 24, 2021. There was documentation of billing to the funding source; however, there was no consent form on file prior to the disclosure of information.
Client #7 was admitted on January 5, 2011 and was discharged June 7, 2021. There was documentation of billing to the funding source; however, there was no consent form on file prior to the disclosure of information.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
By 7/26/21 business office director will facilitate a training with business office staff responsible for having members complete consents. One area of focus of this training will be ensuring that the members are completing all applicable consents prior to receiving treatment.
By 7/26/21 Quality Assurance Specialist will begin weekly auditing checks of releases to ensure they are being filled out in accordance with directives.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person,agency, or organization to whom a disclosure was to be made to on informed and voluntary consent forms in two of seven client records reviewed.
Client #5 was admitted on May 8, 2014 and was discharged May 24, 2021. A release of information form was signed and dated by the client; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure was to be made to.
Client #6 was admitted on October 11, 2019 and was discharged April 14, 2021. A release of information form was signed and dated by the client with a purpose of primary care physician; however, the consent form did not include the specific name of the person, agency or organization to whom the disclosure was to be made to.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 7/26/21 business office director will facilitate a training with business office staff responsible for having members complete consents. One area of focus of this training will be ensuring that the members are specifying the recipient of released information on consents where this is applicable.
By 7/26/21 Quality Assurance Specialist will begin weekly auditing checks of releases to ensure they are being filled out in accordance with directives.
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715.23(d) LICENSURE Patient records
(d) A narcotic treatment program shall prepare a treatment plan that outlines realistic short and long-term treatment goals which are mutually acceptable to the patient and the narcotic treatment program.
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Observations
Based on a review of client records, the facility failed to prepare and document a treatment plan with mutually acceptable goals to the patient and the treatment program in one of seven patient records reviewed.
Patient # 4 was admitted on April 8, 2021 and was active at the time of inspection. There was no documented treatment plan in the patient record as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 7/26/21 Quality Assurance Manager will provide a training to staff around the timeframes, expectations and quality guidelines of completing member treatment plans.
By 7/26/21 Quality Assurance Manager will check charts weekly to ensure that treatment plans were completed in accordance with training directives.
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