INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 16, 2019 of Central Outreach Resource and Referral Center by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Central Outreach Resource and Referral Center 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
|
704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to develop a written policy to address relapse of recovering clinical personnel. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of correction
Central Outreach Center Has created the following plan of correction in response to Deficiencies 704.3 found doing an on-sit Licensure renewal inspection conduced on 10/16/2019
We acknowledge that relapse is common with alcohol and drug Addiction. All staff who are recovering people must report when a relapse happen. We will support employees through a relapse. We will treat subsequent relapses on a case-by-case basis. If the employee has been deemed unsuitable or unfit to continue with this role, suitable alternative roles may be considered where reasonably possible. After the relapse the staff person will be put on probation and required to go to a Rehabilitation Treatment program or MAT program. (Medical Assistance Treatment). The employee will be allowed reasonable time off from work to undergo treatment where needed. This leave will be treated as sick leave and the employee will receive sick pay in accordance with the terms of their sick leave .and if the person refused to go get the help, they need. Then other alternatives shell be pursued, and that is permanent separation of their services (let Go). However, the Employee can Return to Work After the successful completion of treatment, the employee will be put on urine screening two time a week for 4 months and base on their Job responsible, and their Job performance the organization will try to make sure that the employee returns to their existing role. However, if the employee is unable to fulfil their required duties, we will consider alternatives duties.
To ensure that this does not recur the program Director will have trainings on relapse in the work place and review Every staff folder to make sure that ever staff person has sign of on the policy of relapse The Executive Director and the Board will have a review, and will take into account the needs of the Employee and the needs of the organization. The Director will make sure that the employees is aware that disciplinary procedures is in place and begin following subsequent relapses therefore meeting DDAP requirements as stated in the licensure |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel files, employee #1 was not trained in fire extinguisher use upon hire. Employee #1 was hired on June 24, 2001 and was still employed at the time of the inspection. There was no documentation that he employee received the training as of the date of this inspection on October 16, 2019.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction Central Outreach Center in response to Deficiencies 705.28 found doing a site Licensure renewal inspection conducted on 10/16/2019 At the time of hiring an employee shell be train on the responsibility of where the fire extinguisher or located and how to use a fire extinguisher
The program Director will ensure that the following steps should be followed when responding to the use of a fire extinguisher:
1. Select the appropriate type of fire Extinguisher
2. . Discharge the extinguisher within its effective range using the P.A.S.S. technique (pull, aim, squeeze, sweep).PULL... Pull the pin. This will also break the tamper seal.
3. Back away from an Extinguished fire in case it flames up again.
4. AIM... Aim low, pointing the extinguisher nozzle (or its horn or hose) at the base of the fire. NOTE: Do not touch the plastic discharge horn on CO2 extinguishers, it gets very cold and may damage skin.
5. SQUEEZE... Squeeze the handle to release the Extinguishing agent.
6. SWEEP... Sweep from side to side at the base of the fire until it appears to be out. Watch the area. If the fire re-ignites, repeat steps 2 - 4.
7. Evacuate immediately if the extinguisher is empty and the fire is not out. Evacuate immediately if the fire progresses beyond the stage Most fire extinguishers operate using the following P.A.S.S. technique:
If you have the slightest doubt about your ability to fight a fire.... EVACUATE IMMEDIATELY!
To ensure that the staff and ever new hire is trained in the use of the fire Extinguisher they must sign and date the fire extinguisher policy the Program Director will review that ever employee has been training on the use of a fire Extinguisher.
|
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a discussion with the facility director, the facility failed to conduct monthly unannouced fire drills. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 705.28 conduct unannounced fire drills found during a site licensure renewal inspection conducted on 10/16/2019
The program Director will ensure that an unannounced fire drill will take place once a month and documentation of the unannounced fire drill log in the log book will be kept
To ensure that this does not recur, the program Director will review the fire drills log book monthly to ensure that unannounced fire drills has taken place each month. Therefore, meeting as stated in the DDAP licensure regulations
|
705.28 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
|
Observations
Based on a discussion with the facility director, the facility failed to conduct fire drills during normal staffing conditions. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 705.28 in the conduct fire drills during normal staffing conditions
The program Director will ensure that fire Drills will be conducted doing normal staffing hours our hour of operation are 9:00 to 4:00 Monday ? Friday. The log book will be check weekly to make shore that the fire drills are on normal working hours.
To ensure that this does not recur, the Program Director will review the fire drill log book and document the time and hours and the Days to ensure that fire drills took place doing normal staffing hours every month therefore meeting DDAP requirement as state in DDAP regulation
|
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based upon a review of personnel files, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies. Employee #1 was hired on June 24th, 2019 and was still employed at the time of the inspection. There was no documentation in employee #1 ' s personnel file indicating that the employee had been trained on what to do during emergencies as of the date of this inspection. The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 705.28 Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies
The program Director will ensure that all shifts personal has been trained in a pacific task that they will be there responsible to perform doing every fire drill and log in the log book.
To ensure that this does not recur, the program Director will review the fire drills log book monthly to ensure that each shift personal has perform their task and that it is log in the log book
|
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a discussion with Facility Director, the facility failed to prepare alternate exit routes to be used during fire drills.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center has created the following Plan of Correction in response to deficiencies 705.28 Prepare alternate exits route to be used during fire drills found during a site licensure Renewal inspector conducted on 10/16/2018
Program Director will ensure that every other fire drill shell alternate exits each time a drill occurs
To ensure that this does not recur, the program Director will review the fire drills log book monthly to ensure that the exit are alternated every other time that fire drills has taken place and should be log in the log book. Therefore, meeting as stated in the DDAP licensure regulations
|
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
Based on a discussion with the facility director, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 705.28 conduct fire drills on different days of the week, at different times of the Day and on different shifts. found during a site licensure renewal inspection conducted on 10/16/2019
The program Director will ensure that fire drills are conducted on different Days of the week and different time of the Day and different staffing shifts.
To ensure that this does not recur, the program Director will make sure that the staff is a wear of the different changes of the fire drills in the responsibility of different Days of weeks ,and different time of the day and different shifts a review of the fire drills log book shell take place by the Executive Director monthly to ensure that fire drills have taken place different Days of the week and different times of the day and different shifts.
|
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.
|
Observations
Based on a discussion with the facility director, the facility failed to Set off a fire alarm or smoke detector during each fire drill.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center has created the following Plan of Correction in response to deficiencies 705.28 set of fire alarm or smoke detectors during each fire drill. Found during a site licensure Renewal inspector conducted on 10/16/2018
The program Director will ensure that during a fire drills, a fire smoke detector are set of during each drill. a log will be keep. one week a fire alarm will be set off, and the next week a smoke detector will be set off. This shell alternates every other week and log in the log book
To ensure that this does not recur, the program Director will make sure that the staff is aware of the Alternates of the alarm and smoke detector being set of and documented by the Director and the Case Manager in the log book
|
709.22 (b) (1) LICENSURE Governing Body
§ 709.22. Governing body.
(b) The duties of the governing body include, but are not limited to, the following:
(1) Designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document duties of the governing body including: designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 709.22 the duties of the governing body include, but no limited to the following designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly licensure renewal inspection conducted on 10/16/2019
The program Director will ensure that make the correction to the bylaw to include in the Bylaw that the board is responsible for designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly.
To ensure that this does not recur, the program Director and the board shell make the changes to the Bylaw to reflect the duties of the governing body include, but no limited to the following designating the position to serve as project director as the person officially responsible to the governing body either directly or indirectly
|
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to provide written procedures for the management of treatment/rehabilitation services for clients. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 709.24 found during a site licensure renewal inspection conducted on 10/16/2019
The program Director and the governing board has developed a written plan for the coordination of client's treatment and rehabilitation services which includes but no limited to written procedures for the management of treatment and rehabilitation.
To ensure that this does not recur, the program Director and governing body has added to the policy and procedures the written plan for the treatment and rehabilitation and had the Case Manager sign of on the changes to the policy and procedure. therefore, meeting as stated in the DDAP licensure regulations
|
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.
|
Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record #7.Client #7 had their assessement on January 16, 2019. There was documentation that a phone call was made with a contact at another service provider on January 16, 2019; however, there was no proper consent to release information form signed by the client prior to disclosure.The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.28 found doing a site Licensure renewal inspection conducted on 10/16/2019 based on the review of client record the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in client record #7 client 7 had their assessment on January 16 2019: there was documentation that a phone call was made with a contact at another service provider on January 16 2019 however there was no proper consent to release information form signed by the client prior to disclosure.
The program Director will ensure that confidentiality the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. the Director shells develop a sign on sheet on the back of the client files so that it can be double check and sign off that all consent is sign and dated and every folder will be check by another Case Manager as a peer review
To ensure that this does not recur, the program Director will review the client folder to check that all consent forms are signed and dated and peer review check list in the back of every folder for a Case Manager can do a client file check list/ or Peer review. therefore, meeting as stated in the DDAP licensure regulations
|
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in client record #'s 1, 2, and 3. Client #1 had their assessment completed on July 25, 2019. A consent to release form was signed and dated on July 31, 2019 to the funding source that allowed for the release of "other". Client #2 had their assessment completed on May 23, 2019. A consent to release form was signed and dated on May 25, 2019 to the funding source that allowed for the release of "other".Client #3 had their assessment completed on January 25, 2019. A consent to release form was signed and dated on January 31, 2019 to the funding source that allowed for the release of "other". These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 709.28 confidentiality the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record the facility failed to keep disclosures of client identifying information with in the limits established by 4 pa code 255.5 for releases of information in client record # 1,2,and 3 client #1 had their assessment completed on July 25 2019 A consent to release form was signed and dated om May 25 2019 to the finding source that allowed for the release of other client #2 had their assessment completed on May 23 2019 a consent to release form was sign on date May 25 2019 to the finding source that allowed the release of other. Client #3 had their assessment completed on January 25 2019 a consent to release form was signed and date on January 31 2019 to the funding source that allowed for the release other. found during a site licensure renewal inspection conducted on 10/16/2019
The program Director will ensure that confidentiality the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. the Director shells develop a sign on sheet in the back of the client files so that it can be double check and sign off that all consent is sign and dated and every folder will be check by another Case Manager as a peer review
To ensure that this does not recur, the program Director will review the client folder to check that all consent forms are signed and dated and peer review check list in the back of every folder for a Case Manager can do a client file check list/ or Peer review. therefore, meeting as stated in the DDAP licensure regulations
|
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
Based on a review of seven client records, the facility's client rights policy failed to include documentation of all the required client rights, including that A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 709.24 found during a site licensure renewal inspection conducted on 10/16/2019 clients rights the project shall develop written policies and procedures on client right and document written acknowledgement by clients that they have been notified of those right to inspect their own records the project facility or clinical director may 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. based on review of seven clients records the facility client right policy failed to included documentation of all the required client right including that client have the right to inspect their own records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reason for removing sections shall be documented in the record.
The program Director will ensure that Grievance and Appeal 8.08. The Director shells develop a sign on sheet on the back of the client files so that it can be double check and sign off that Grievance and appeal has been signed and dated and every folder will be check by another Case Manager as a peer review
To ensure that this does not recur, the program Director and governing body has added the new version of 8.08 to the policy and procedures manual. the new revised version of 8.08. The Case Manager will sign of on the changes, also there will be a peer review on the back of the client file to make sure that every clients file has been check by another Case Manager therefore, meeting as stated in the DDAP licensure regulations
Section 8.08 Grievance and Appeal Process
The primary objective of the grievance and appeal process is to promote a step-by-step effort at reconciliation between an aggrieved individual and the SCA. Contracted treatment providers and other agencies may have separate grievance and appeal protocols arising from the individual's direct involvement with those programs; however, the SCA's policy must be followed in cases where the grievance concerns an administrative or financial decision made by, or on behalf of, the SCA. The SCA must have an expeditious, accessible, fair, and uniform appeal process in place for resolving grievances.
A grievance is defined as a written complaint by an individual of the decision made by the SCA. An appeal is the process utilized to resolve a grievance. At a minimum, individuals must be able to file a grievance in the four areas listed below.
1) Denial or termination of services;
2) LOC determination;
3) Length of stay in treatment; and
4) Violation of the individual's human or civil rights.
If the SCA chooses to include additional categories (e.g., "other") that an individual can grieve, it must be made clear what those areas specifically include.
In the event an individual grieves a treatment funding decision related to a reduction or termination of services or length of stay in treatment, the SCA is required to continue funding treatment services at the current level of engagement until the appeal is resolved. This applies to all treatment services, including the provision of Medication Assisted Treatment (MAT).
SCAs are required to have an appeal process that includes the following:
1) A policy that describes, at a minimum, a two-stage appeal process where:
a. The first level of appeal must be made to a panel made up of SCA staff or a supervisory level staff person, none of whom are directly involved in the dispute. A decision by the SCA must be rendered within seven days upon receipt of the grievance at each level of appeal. In addition, the SCA must inform both the individual and DDAP of the outcome within seven days via the DDAP-approved Grievance and Appeal Reporting form (DDAP-EFM-1009) which is published on DDAP's website (www.ddap.pa.gov) under the DDAP Document Library, Forms page. It is imperative that client identifying information is not included or attached to this form.
b. The final level of appeal must be made to an independent review board or hearing panel that is comprised of an odd number (no less than three) of members who have no financial, occupational, or contractual agreements with the SCA. A decision by the panel chairperson must be rendered within seven days upon receipt of the grievance at each level of appeal. Access to confidential records must be in accordance with state and federal confidentiality regulations. The Department of Drug and Alcohol Programs, the Department of Human Services, or the members of the SCA's governing body (County Executive, County Commissioners, or governing Board of Directors) may not serve as the independent review board or hearing panel. The SCA is required to identify the composition and number of members designated as the independent review board or hearing panel. In addition, the SCA must inform both the individual and DDAP of the outcome within seven days via the DDAP-approved Grievance and Appeal Reporting form (DDAP-EFM-1009). It is imperative that client identifying information is not included or attached to this form.
2) Notification: The individual must sign-off that they have been notified about the following areas:
a. The grievance and appeal policy that outlines the four areas that an individual can grieve with the SCA;
b. The need for a signed consent form from the individual so confidential client information relating to the appeal can be provided to an independent review board for the purpose of rendering a decision on the appeal;
c. The right to have access to all documentation pertaining to the resolution of the grievance within the confines of state and federal confidentiality regulations;
d. The right to be involved in the process and have representation by means of a client advocate, case manager, or any other individual chosen by the individual at each level of appeal; and
e. When the appeal is related to termination of funding for or reduction of treatment services, including the provision of MAT, funding for service continues at the current level of engagement until the appeal is resolved, unless the individual agrees otherwise.
GRIEVANCE AND APPEAL REPORTING FORM
SCA: _________________________ Level: ____________
Issue: _________________________ Date: _____________
Client ID #: _________________________
Briefly describe the client's grievance with the SCA: (Include date grievance was filed with the SCA).
Briefly describe the outcome of the grievance and the basis for the decision: (Include date of review).
Grievance Resolved: Yes ( ) No ( )
Submit to:
One Penn Center, 5th Floor
2601 N. 3rd Street
Harrisburg, PA 17110
Email: RA-DA_GAMBLING@pa.gov
Ph: 717-783-8200 Fax: 717-787-6285
Signature Page of SCA Bureau of Drug and Alcohol Grievance Policy
Revised 8/2019
I have received the SCA grievance policy from this facility.
_____________________________________________________________________________
Client Signature / Date
______________________________________________________________________________
Facility Representative / Date
|
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.
|
Observations
Based on a review of seven client records, the facility's client rights policy failed to include documentation of all the required client rights including that 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. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Section 8.08 Grievance and Appeal Process
The primary objective of the grievance and appeal process is to promote a step-by-step effort at reconciliation between an aggrieved individual and the SCA. Contracted treatment providers and other agencies may have separate grievance and appeal protocols arising from the individual's direct involvement with those programs; however, the SCA's policy must be followed in cases where the grievance concerns an administrative or financial decision made by, or on behalf of, the SCA. The SCA must have an expeditious, accessible, fair, and uniform appeal process in place for resolving grievances.
A grievance is defined as a written complaint by an individual of the decision made by the SCA. An appeal is the process utilized to resolve a grievance. At a minimum, individuals must be able to file a grievance in the four areas listed below.
1) Denial or termination of services;
2) LOC determination;
3) Length of stay in treatment; and
4) Violation of the individual's human or civil rights.
If the SCA chooses to include additional categories (e.g., "other") that an individual can grieve, it must be made clear what those areas specifically include.
In the event an individual grieves a treatment funding decision related to a reduction or termination of services or length of stay in treatment, the SCA is required to continue funding treatment services at the current level of engagement until the appeal is resolved. This applies to all treatment services, including the provision of Medication Assisted Treatment (MAT).
SCAs are required to have an appeal process that includes the following:
1) A policy that describes, at a minimum, a two-stage appeal process where:
a. The first level of appeal must be made to a panel made up of SCA staff or a supervisory level staff person, none of whom are directly involved in the dispute. A decision by the SCA must be rendered within seven days upon receipt of the grievance at each level of appeal. In addition, the SCA must inform both the individual and DDAP of the outcome within seven days via the DDAP-approved Grievance and Appeal Reporting form (DDAP-EFM-1009) which is published on DDAP's website (www.ddap.pa.gov) under the DDAP Document Library, Forms page. It is imperative that client identifying information is not included or attached to this form.
b. The final level of appeal must be made to an independent review board or hearing panel that is comprised of an odd number (no less than three) of members who have no financial, occupational, or contractual agreements with the SCA. A decision by the panel chairperson must be rendered within seven days upon receipt of the grievance at each level of appeal. Access to confidential records must be in accordance with state and federal confidentiality regulations. The Department of Drug and Alcohol Programs, the Department of Human Services, or the members of the SCA's governing body (County Executive, County Commissioners, or governing Board of Directors) may not serve as the independent review board or hearing panel. The SCA is required to identify the composition and number of members designated as the independent review board or hearing panel. In addition, the SCA must inform both the individual and DDAP of the outcome within seven days via the DDAP-approved Grievance and Appeal Reporting form (DDAP-EFM-1009). It is imperative that client identifying information is not included or attached to this form.
2) Notification: The individual must sign-off that they have been notified about the following areas:
a. The grievance and appeal policy that outlines the four areas that an individual can grieve with the SCA;
b. The need for a signed consent form from the individual so confidential client information relating to the appeal can be provided to an independent review board for the purpose of rendering a decision on the appeal;
c. The right to have access to all documentation pertaining to the resolution of the grievance within the confines of state and federal confidentiality regulations;
d. The right to be involved in the process and have representation by means of a client advocate, case manager, or any other individual chosen by the individual at each level of appeal; and
e. When the appeal is related to termination of funding for or reduction of treatment services, including the provision of MAT, funding for service continues at the current level of engagement until the appeal is resolved, unless the individual agrees otherwise.
GRIEVANCE AND APPEAL REPORTING FORM
SCA: _________________________ Level: ____________
Issue: _________________________ Date: _____________
Client ID #: _________________________
Briefly describe the client's grievance with the SCA: (Include date grievance was filed with the SCA).
Briefly describe the outcome of the grievance and the basis for the decision: (Include date of review).
Grievance Resolved: Yes ( ) No ( )
Submit to:
One Penn Center, 5th Floor
2601 N. 3rd Street
Harrisburg, PA 17110
Email: RA-DA_GAMBLING@pa.gov
Ph: 717-783-8200 Fax: 717-787-6285
Signature Page of SCA Bureau of Drug and Alcohol Grievance Policy
Revised 8/2019
I have received the SCA grievance policy from this facility.
_____________________________________________________________________________
Client Signature / Date
______________________________________________________________________________
Facility Representative / Date
|
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
|
Observations
Based on a review of the policy and procedure manual the facility failed to develop and implement policies and procedures to respond to the physical assault or sexual assault by staff or a client. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019 the project shell develops and implement policies and procedure to respond to the following unusual incidents Physical assault or sexual assault by staff or a client
The program Director will ensure that reporting of unusual incidents. In the case of physical or sexual assault by staff or a client, the incident will immediately be reported to Program Director, who will notify the appropriate authority and document the incident. The staff member who reported the incident will complete and internal Incident Report, which is forwarded automatically to the Executive Director for review and analysis. The staff member who reported the incident will also complete a written unusual incident report and file it with DDAP
To ensure that this does not recur, the program Director will have all staff be retrained on the policies and procedure for unusual incidents and to signed off that they have received the training., therefore, meeting as stated in the DDAP licensure regulations
|
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
|
Observations
Based on a review of the policy and procedure manual the facility failed to develop and implement policies and procedures to respond to the Selling or use of illicit drugs on the premises. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019 the project shell develops and implement policies and procedure to respond to the following unusual incidents. Selling or use of illicit drugs on the premises
The program Director will ensure that reporting of unusual incidents. In the case that illicit drug use or drug sales on the property occur, the Clinical Supervisor will be notified. If the incident involves a current client, the Clinical Supervisor will address the client and refer him/her to the appropriate level of care, and she/he will be discharged from the program. If the incident does not involve a current client, the Clinical Supervisor will notify the appropriate authorities of the illegal activity on the premises. The staff member who reported the incident will complete an internal Incident Report, which is forwarded automatically to the Executive Director for review and analysis.
To ensure that this does not recur, the program Director will have all staff be retrained on the policies and procedure for unusual incidents and to signed off that they have received the training., therefore, meeting as stated in the DDAP licensure regulations
|
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
|
Observations
Based on a review of the policy and procedure manual the facility failed to develop and implement policies and procedures to respond to the Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019 the project shell develops and implement policies and procedure to respond to the following unusual incidents Death or serious injury due to trauma, suicide medication error or unusual circumstance while in residential treatment or when know by the facility for ambulatory service
The program Director will ensure that reporting of unusual incidents. In the case of death, serious injury due to trauma, suicide, medication error, or unusual circumstances while in residential treatment or, when known by the facility, for ambulatory services, the appropriate authorities will be notified for assistance if medical attention is required, such as 9-1-1. The staff member who reported the incident will complete an internal Incident Report, which is forwarded automatically to the Executive Director for review and analysis. The staff member who reported the incident will also complete a written unusual incident report and file it with DDAP.
To ensure that this does not recur, the program Director will have all staff be retrained on the policies and procedure for unusual incidents and to signed off that they have received the training., therefore, meeting as stated in the DDAP licensure regulations
|
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
|
Observations
Based on a review of the policy and procedure manual the facility failed to develop and implement policies and procedures to respond to the Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than one day. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019 the project shell develops and implement policies and procedure to respond to the following unusual incidents Significant disruption of services due to disaster such as fire storm flood or other occurrence which closes the facility for more than 1 day
The program Director will ensure that reporting of unusual incidents. In the case of significant disruption of services due to disaster such as fire, storm, flood, or other occurrence when closes the facility for more than one day, clients will be referred to another project site, or a different outpatient program in the community. The Program Director will be responsible to also complete a written unusual incident report and file it with DDAP.
To ensure that this does not recur, the program Director will have all staff be retrained on the policies and procedure for unusual incidents and to signed off that they have received the training. The project Manager will complete a written report and file it with DDAP therefore, meeting as stated in the DDAP licensure regulations
|
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
|
Observations
Based on a review of the policy and procedure manual the facility failed to develop and implement policies and procedures to respond to the Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the Theft, burglary, break-in or similar incident at the facilityThe findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019 the project shell develops and implement policies and procedure to respond to the following unusual. Theft burglary break in or similar incident at the facility.
The program Director will ensure that reporting of unusual incidents in the case of theft, burglary, break-in or similar incident, the incident will immediately be reported to Program Director, who will notify the appropriate authority and document the incident. The staff member who reported the incident will complete an internal Incident Report, which is forwarded automatically to the Executive Director for review and analysis.
To ensure that this does not recur, the program Director will have all staff be retrained on the policies and procedure for unusual incidents and to signed off that they have received the training. The project Manager will complete a written report and file it with DDAP therefore, meeting as stated in the DDAP licensure regulations
|
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of the policy and procedure manual the facility failed to develop and implement policies and procedures to respond to an event at the facility requiring the presence of police, fire or ambulance personnelThe findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019 the project shell develops and implement policies and procedure to respond to the following unusual. Event at the facility at the facility requiring the presence of policy, fire or ambulance personnel
The program Director will ensure that reporting of unusual incidents In the case of an event at the facility requiring presence of police, fire or ambulance personnel, the staff member on duty will be responsible to call for emergency personnel immediately, and report the incident to the Program Director. The staff member who reported the incident will complete an internal Incident Report, which is forwarded automatically to the Executive Director for review and analysis. The staff member who reported the incident will also complete a written unusual incident report and file it with DDAP.
To ensure that this does not recur, the program Director will have all staff be retrained on the policies and procedure for unusual incidents and to signed off that they have received the training. The project Manager will complete a written report and file it with DDAP therefore, meeting as stated in the DDAP licensure regulations
|
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
|
Observations
Based on a review of the policy and procedure manual the facility failed to develop and implement policies and procedures to respond to Fire or structural damage to the facility. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019 the project shell develops and implement policies and procedure to respond to the following unusual incidents. Fire or structural damage to the facility
The program Director will ensure that reporting of unusual incidents in the case of an event involving fire or structural damage to the facility, the staff member on duty will be responsible to evacuate the premises according to policy, call for emergency services, and report the incident to the Program Director. The staff member who reported the incident will complete an internal Incident Report, which is forwarded automatically to the Executive Director for review and analysis.
To ensure that this does not recur, the program Director will have all staff be retrained on the policies and procedure for unusual incidents and to signed off that they have received the training. The project Manager will complete a written report and file it with DDAP therefore, meeting as stated in the DDAP licensure regulations
|
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
|
Observations
Based on a review of the policy and procedure manual the facility failed to develop and implement policies and procedures to respond to an Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019 the project shell develops and implement policies and procedure to respond to the following unusual incidents. Outbreak of a contagious disease requiring Center for Disease control (CDC) notification
The program Director will ensure that reporting of unusual. Incidents. In the case of an event involving the outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification, the staff member on duty will be responsible to assist the client (s) in obtaining proper treatment for the outbreak, notify the Program Director, and complete an internal Incident Report, which is forwarded automatically to the Executive Director for review and analysis. The Program Director will be responsible to notify the CDC, and complete a written unusual incident report and file it with DDAP.
To ensure that this does not recur, the program Director will have all staff be retrained on the policies and procedure for unusual incidents and to signed off that they have received the training. The Program Director will be responsible to notify the CDC, and complete a written unusual incident report and file it with DDAP. therefore, meeting as stated in the DDAP licensure regulations
|
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to provide policies and procedure that inlcude Documentation of the unusual incident. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019 the project shell develops and implement policies and procedure to respond to the following unusual incidents. Policy and procedures must include the following Prompt review and identification of the causes directly or indirectly
The program Director will ensure that reporting of unusual Incidents. Document unusual incidents internally, and place a printed version of the incident in the Health & Safety binder. Incidents that meet qualifications for DDAP reporting are completed on a DDAP-specific form, and also placed in the Health & Safety binder after being reported to DDAP.
To ensure that this does not recur, the program Director will have all staff be retrained on the policies and procedure for unusual incidents and to signed off that they have received the training. The Program Director will be responsible that the Incidents meet qualifications for DDAP reporting are completed on a DDAP-specific form, and also placed in the Health & Safety binder after being reported to DDAP
|
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to provide policies and procedure that inlcude prompt review and identification of the causes directly or indirectly responsible for the unusual incident. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019. Policy and procedures must include the following Prompt review and identification of the causes directly or indirectly responsible for the unusual incident
The program Director will ensure that reporting of unusual Incidents. All printed and written internal Incident Reports are promptly reviewed by the Program Director and Executive Director to ensure they were handled properly, and that direct and indirect causes are identified.
To ensure that this does not recur, the program Director will have all staff be retrained on the policies and procedure for unusual incidents and to signed off that they have received the training. The Program Director will ensure they were handled properly, and that direct and indirect causes are identified.
|
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to provide policies and procedure that inlcudes Implementation of a timely and appropriate corrective action plan, when indicated. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019. Policy and procedures must include the following Implementation of a timely and appropriate corrective action plan when indicated
The program Director will ensure that reporting of unusual Incidents During the review, the Program Director and Executive Director are responsible to ensure that a timely and appropriate corrective action plan has been included by the staff member on duty, when indicated.
.
To ensure that this does not recur, the program Director will have all staff be retrained on the policies and procedure for unusual incidents and to signed off that they have received the training. The Program Director will ensure they were handled properly, and that direct and indirect causes are identified.
|
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to provide policies and procedure that inlcudes Ongoing monitoring of the corrective action plan. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019 policies and procedure must include the following Ongoing Monitoring of the corrective action plan
The program Director will ensure that reporting of unusual incidents The Program Director is responsible to provide ongoing monitoring of the corrective action plan, helping to ensure that the incident does not occur again. The Executive Director reviews and analyzes Incident Reports on a quarterly basis to identify and correct any trends in incidents.
To ensure that this does not recur. The Executive Director will reviews and analyzes Incident Reports on a quarterly basis to identify and correct any trends in incidents that seems to be recurring .
|
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to provide policies and procedure that inlcudes Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. The findings were discussed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.34 found doing a site Licensure renewal inspection conducted on 10/16/2019 policies and procedure must include the following reporting mechanism to ensure that reporting of an entity is in compliance with the state and federal confidentiality laws
The program Director will ensure that reporting of unusual incidents All incident reports avoid using identifying information of clients, and are strictly monitored by the facility, to ensure compliance with State and Federal confidentiality laws.
To ensure that this does not recur. The Executive Director will monitor all incidents on a regular basis and document incident in the health and safety binder therefore, meeting as stated in the DDAP licensure regulations
|
709.44(a)(5) LICENSURE Records of Services
709.44. Client records.
(a) The project shall maintain a client record on an individual which shall include, but not be limited to:
(5) Record of services provided.
|
Observations
Based on a review of client records and discussion with the facility director, the facility failed to provide a complete record of services in seven out of seven records reviewed. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 709.44 The project shall maintain a client record on individual which shall include but no limited to Record of services provided
The program Director will ensure that reporting of unusual incidents. The Client records, regardless of format, shall be readily accessible for a minimum of 4 years following the discharge of a client. If the project discontinues operation, it shall make known to the Department where its records are stored.
To ensure that this does not recur, at our next staff meeting the program Director will have all staff be retrained on the policies and procedure for client's record., the program director will provide written correspondence to all staff regarding the expectation of compliance with DDAP regulation 709.44. therefore, meeting as stated in the DDAP licensure regulations
|