INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 3 through 4, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on February 2, 2007.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Documentation of HIV/AIDS training was not provided for employee's #4, 5 and 7.
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Plan of Correction
All new employees and employees listed will attend state mandated HIV/AIDS 6 hour training on March 23, 2007 at Kensington Hospital. The training will be given by a State certified trainer. The Clinical Supervisor has already scheduled this training and will monitor for compliance |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
There were no paper towels or mechanical dryers in the client bathrooms.
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Plan of Correction
All client rooms have been equipped with individual paper towel dispensers. The Facilities Director has also instructed the Housekeepers assigned to this floor to check dispensers on a daily basis for availability. The Facilities Director will monitor compliance by making random checks on the patient floor. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The written fire drill record does not include the exit route used or number of persons in the facility at the time of the drill.
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Plan of Correction
The Facilities Director sent a written request to the Fire Drill Company to assure all fire drill documentation includes the exit route used, as well as, the number of persons in the facility at the time of the drill. The Facilities Director will follow-up to assure the Company has this information on the next fire drill's documentation report. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Alternate exit routes were not used during fire drills.
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Plan of Correction
The Facilities Director sent a written request to the Fire Drill Company to assure fire drills utilize alternate exit routes. The Facilities Director will follow-up to assure the Company utilizes alternate exit routes. |
711.61(c)(3)(i) LICENSURE Medical History
711.61. Intake and admission.
(c) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Family medical history was not documented in three of six client records reviewed, #2, 3 and 6.
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Plan of Correction
All intake/admission paperwork is being revised and upon completion, all staff will be in-serviced on the new forms and appropriate documentation. In-service to staff scheduled for 2/4/07 and will be given by the Clinical Supervisor. The Clinical Supervisor will monitor compliance by monthly random chart reviews. |
711.61(c)(6) LICENSURE Psychosocial Evaluation
711.61. Intake and admission.
(c) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Psychosocial evaluations were a repeat of the historical data reported by the client and did not include the counselor's assessment.
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Plan of Correction
Counselors were provided with a detailed explanation of the State's requirements for biopsychosocial completion during the exit conference. In addition, the biopsychosocial form has been revised to provide additional space for counselors to write a detailed narrative of the patient's assessment. All staff will be in-serviced on the new forms and the appropriate documentation. In-service is scheduled for 2/4/07 and will be given by the Clinical Supervisor. The Clinical Supervisor will monitor compliance by monthly random chart reviews. |
711.62(c)(2) LICENSURE Informed & Voluntary Consent
711.62. Client records.
(c) Confidentiality.
(2) 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:
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Observations
Client record #6 contained documentation that information was released that exceeded the specific information to be released on the signed consent form for that agency. The release of information must be informed and voluntary.
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Plan of Correction
Clinicians received training on the importance of patient confidentiality on 1/7/07, as well as, receiving a copy of the State's regulations on disclosure. The Clinical Supervisor will monitor compliance through monthly randow chart reviews. |
711.62(c)(2)(ii) LICENSURE Specific Information Disclosed
711.62. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
The specific information released to BHSI exceeded that allowed by 4 Pa. Code 255.5 in seven of seven client records reviewed. Specific drugs of abuse and prescribed medications with dose and frequency were released.
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Plan of Correction
BHSI paperwork has been revised by deleting all mention of specific drugs of abuse and prescribed medications with dose and frequency on 1/7/07 to meet Code 255.5. All staff was also trained on the revisions on 1/7/07. The Clinical Supervisor will monitor for compliance through monthly random chart reviews. |
711.65(a) LICENSURE Written Termination Notice
711.65. Notification of termination.
(a) The project director shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Written notification was not provided to one of two client records reviewed, #7.
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Plan of Correction
Staff was in-serviced on the importance of providing clients with notification of involuntary termination. Staff was also re-introduced to the form and to the Hospital's Policies & Procedures on involuntary termination. The Clinical Supervisor will monitor for compliance through weekly chart reviews. |