INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 9-10, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, treatment Trends Inc.-Half-way Home of the Lehigh Valley was found to be not 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 the facility's Staffing Requirements Facility Summary Report, staff schedules and a conversation with the facility staff, the facility failed to have CPR coverage during the following shift(s).January 6, 2017- 3rd shiftJanuary 7, 2017-1st and 3rd shiftsJanuary 8, 12 and 13, 2017- 3rd shiftJanuary 14, 2017-1st and 3rd shiftsJanuary 15, 19 and 20, 2017-3rd shiftJanuary 21, 2017-1st and 3rd shiftsJanuary 22, 26 and 27, 2017-3rd shiftJanuary 28, 2017-1st and 3rd shiftsJanuary 29, February 2 and 3, 2017-3rd shiftFebruary 4, 2017-1st and 3rd shiftsFebruary 5 and 9, 2017-3rd shiftFirst shift is from 8 a.m. to 4 p.m.; third shift is from 12 a.m. to 8 a.m.This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
The program director will ensure all shifts are covered by adequate number of CPR certified staff. Moving forward the program director will work with local outside resources to ensure training is received within the first 30 days of employment. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection conducted on February 9, 2017, the facility failed to ensure privacy by allowing unobstructed visual access from the hallway during counseling sessions for counseling offices located in the basement. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The maintenance staff has installed window coverings on the windows in the counseling offices. The program director and clinical supervisor will meet with clinical staff to review the regulation. The Project Director will periodically monitor counseling sessions to ensure the windows in the counseling areas are properly covered during therapy sessions. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
|
Observations
During a physical plant inspection conducted on February 9, 2017, it was observed that the facility was storing discharged client records in boxes in the administrative storage area located in the basement. Although the door to this area was locked it was confirmed that non-clinical staff have keys to this area. This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
The program director met with the house manager following the physical plant tour on 2/10/17 to address moving those boxes to the chart file room located near the resident laundry area. Keys to this area is held only by the clinical staff of the program. The program director inspected the facility on 2/15/17 to ensure that these changes have been made. During the staff meeting on 2/16/17, the issue of proper chart storage was discussed. |
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:
|
Observations
Client records were reviewed on February 9-10, 2017. The facility failed to obtain a valid consent to release information in following client records.Client #1 was admitted on 10/12/16 and was an active client at the time of the inspection. Two consent to release information forms, dated 10/7/16, to a government agency and a funding source, did not indicate the purpose of the release.Client #2 was admitted on 11/18/16 and was an active client at the time of the inspection. Two consent to release information forms, dated 11/18/16, to a government agency and a funding source, did not specify the information to be release or indicate the purpose of the release. Additionally, a consent to release information form to a government agency dated 11/18/16, did not indicate the purpose of the release.Client #3 was admitted on 12/29/16 and was an active client at the time of the inspection. Two consent to release information forms, dated 12/12/16, to a government agency and a funding source, did not indicate the purpose of the release. Additionally, a consent to release information form to a government agency dated 12/29/16, did not indicate the purpose of the release.Client #4 was admitted on 9/27/16 and discharged on 11/16/16. Two consent to release information forms, dated 8/10/16, to a government agency and a funding source, did not indicate the purpose of the release. Client #6 was admitted on 11/21/16 and discharged on 1/22/17. Two consent to release information forms, dated 10/3/16/16, to a government agency and a funding source, did not indicate the purpose of the release. Client #7 was admitted on 11/22/16 and discharged on 1/4/17. Two consent to release information forms, dated 11/18/16, to a government agency and a funding source, did not indicate the purpose of the release. This information was reviewed with the facility staff during the licensing inspection.
|
Plan of Correction
The program director met with the admission coordinator for supervision on 2/22/17 to review and address these discrepancies. New releases of information where completed with all current residents of the program. Program director worked with software designer on 2/13/17 to ensure proper information is getting populated to the releases at the time of admissions. Admissions coordinator will review every release of information at the time of admission for correctness. Client #1 completed a new releases for the government agency and funding source ensuring purpose of the release are indicated.
Client #2 completed a new release forms for the government agency and funding source and reflect the information to be released along with purpose of the release.
Client #3 completed new releases for government agency and funding source ensuring the purpose of the releases are indicated.
Client #4 No Action was taken as client is no longer in treatment.
Client #6 No Action was taken as client is no longer in treatment.
Client #7 No Action was taken as client is no longer in treatment.
|