INITIAL COMMENTS
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This report is a result of an onsite licensure renewal and methadone monitoring inspection. The inspection was conducted on September 12 - 14, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite inspection, Alliance Medical Services 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 the inspection:
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Plan of Correction
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705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
During the physical plant inspection conducted on September 14, 2016, the facility failed to have a heater permanently mounted. A heater that was not permanently installed was observed in an individual office.These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
The facility failed the heating and cooling portion of the physical plant inspection by having a non-mounted heater present.
Portable heater was removed from the facility on 9/14/16.
To make sure this deficiency will not occur in the future Safety officer will conduct regular checks to make sure all safety regulations are being met. All staff will be reminded that no external heating sources are not allowed within the facility and this information will be included in new staff orientation.
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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
The facility failed to obtain an informed and voluntary consent in six patient records reviewed during the inspection on September 12 - 13, 2016.Patient # 1 was admitted on 1-21-2016 and discharged on 4-26-2016. A release of information was signed on 1-8-2016, and did not include an expiration date. Patient #3 was admitted on 1-10-2014 and was discharged on 2-15-2016. A release of information was signed on 10-26-2015, and did not include specific information to be disclosed, purpose of disclosure and an expiration date.Patient # 6 was admitted on 1-11-2016. A release of information was signed on 1-11-2016 and on 7-20-2016, and did not include a valid expiration date.Patient # 7 was admitted on 3-17-2016. A release of information was signed by the patient on 3-7-2016, and was signed by the counselor on 3-17-2016, and did not indicate the agency to whom the disclosure would be made.Patient #9 was admitted on 7-22-2016. A no-show list, dated 8-8-2016 included full names of other patients, was found in patient record #9.Patient # 10 was admitted on 5-19-2016. A release of information was signed on 7-15-2016 and did not indicate specific information to be disclosed.These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
The facility failed to obtain appropriately completed informed and voluntary consent in patient records.
Come October 17th 2016 the SMART electronic records system will be implemented at this facility. All informed and voluntary consents will be completed within the system, which will require form to be completed before submission into the patient record.
A review of how to appropriately complete informed and voluntary consents will be conducted in staff meeting by Facility Director & Clinical Supervisor.
Facility Director, Clinical Supervisor, & Lead Counselor will continue to conduct regular record reviews to ensure accuracy and completeness of records.
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