INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 21, 2017 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, Open Door Counseling at Mazzoni 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:
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on April 21, 2017 at approximately 02:50 P.M., it was observed that the facility's bathroom for client and staff use did not contain a working exhaust fan or window at the time of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program is in the process of relocating to a new facility with new bathrooms that are built to code and include proper ventilation. Certificate of Occupancy for the new location is in the process of being secured and will be forwarded to DDAP by the Program Director. The move is scheduled for May 24, 2017. Once occupying the new facility, the construction in the bathroom will not change and therefore will continue to meet standards. The facility manager will monitor ongoing for compliance. |
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 the review of seven 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 # 1.
Client #1 was admitted on 02/01/16 and was discharged on 11/21/16. The record contained a letter to a government agency, dated 02/29/16, which identified the client's presence in treatment. However, the record did not contain a consent to release information form for the agency prior to the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed process and protocol for obtaining client permission to release information with all staff. Staff asked questions and now more fully understand the requirements. Program Director will continue to review policies with staff on a quarterly basis during future team meetings. Quality Assurance Specialist and Program Director will monitor for ongoing compliance through spot checks and regular chart reviews. |
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.
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Observations
Based on a review of seven client records, all seven records lacked documentation verifying the client's written acknowledgement that they had been notified of the following client rights: the ability to inspect their records, the right to appeal a decision limiting access to their records, the right to request the correction of inaccurate information in the record, and the right to submit a rebuttal to their record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
While this information is posted in view in the lobby, we understand that 709.30 requires clients to sign off on an acknowledgement of receipt of this information. As a result, the Client Rights form was updated by Program Director to include the ability to inspect their records, the right to appeal a decision limiting access to their records, the right to request the correction of inaccurate information in the record, and the right to submit a rebuttal to their record. The updated form is currently in circulation and staff have been made aware of the change by the Program Director. The Registrar will present clients with new form at their next upcoming visit and obtain signatures from active clients which will be retained in their charts. Quality Assurance Specialist will monitor for ongoing compliance using spot checks and regular chart reviews. |