INITIAL COMMENTS
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This report is a result of an on-site licensure inspection conducted on April 3-4, 2019 by staff from the Department of Drug and Alcohol Programs and Bureau of Quality Assuarance for Prevention & Treatment. Based on the findings of the on-site investigation, Hispanic American Organization was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that the counselor assistant was supervised by a full-time clinical supervisor or counselor. Employee #2 who serves as the facility director, clinical supervisor and as a counselor has to split her workweek between three positions and cannot be considered as a full-time in any of the three positions. Therefore she cannot be considered as a full-time clincal supervisor or full-time counselor.
This was discussed with facility staff via a telephone conversation following the onsite inspection.
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Plan of Correction
Employee #2 has been assigned to the position and functions, exclusively as the Full-Time Clinical Supervisor, she will be in charge of the team supervisions, and providing close supervision of the counselor assistant throughout her required supervision period. Employee #2 will also hold a small caseload of 1-5 clients.
Moving forward, the facility will ensure that all newly hired clinical staff meet the qualifications as a counselor and will only hire a counselor assistants once a the facility has an individual who can serve as a full time clinical supervisor or full time counselor that meets the requirements noted at 704.9.
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
During the inspection conducted on April 3-4, 2019, the licensing specialist observed the Emergency Exit stairway leading from the Drug and Alcohol floor to be obstructed by office furniture including file cabinent, trash can, Office Desk and an industrial commercial fan. Based upon observation the facility failed to ensure that stairways, hallways and exits are unobstructed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The organization has an empty building in another facility in Allentown, and decided to use it as a storage area. The equipment that was in the first floor blocking the exit door was removed and stored at that facility. The organization has implemented a monthly compliance walk thru of all exits to ensure that there is no object blocking the areas. The Corporate compliance staff will be in charge of the monthly walk through.
At this time the Emergency Exit stairway leading from the Drug and Alcohol, floor has been clear of all obstructing office furniture,file cabinet, trash cans, office desk and an the industrial commercial fan. The facility currently ensure that stairways, hallways and exits are unobstructed.
The Director and the Corporate Compliance Officer has implemented the corrective action plan since May 2019. They are monitoring and documenting walk through. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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
Based on a review of the facilities fire drill log for 2018. The facility failed to maintain and document all components required for fire drill logs. The facility failed to indicate the emergency exit/route used, whether the fire alarm or smoke detector was operative in addition to any problems encountered during the drills.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility compliance officer revised the log to include space to document the emergency exit/route used, whether the fire alarm or smoke detector was operative, in addition to document any problems encountered during the drills. Unannounced fire drills will be conducted on various dates prior to the last day of the month. The facility director will review the log with the compliance officer to ensure all the required information has been documented. If there is anything not properly documented and additional drill will be held.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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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 #8. Additionally, client record #8 was missing specific information to be released or the name of the person who witness completion of the releases.
Client #8 was admitted 7.2.18 and discharged 7.20.18. A consent to release form was signed and dated for Eagleville Hospital, Nuestra Clinica and Firetree on 7.9.18 however did not indicate what information was to be released. The releases of information were also missing a witness signature indicated that the release was signed with staff.
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Plan of Correction
The clinical supervisor provided a training on the importance of correctly completing consent to release information forms to all clinical and intake staff on 5-17-19. This included an overview of what all must be on a consent to release information form and what may be released when 4 Pa. Code 255.5(b) is applicable.
To ensure that the deficiency does not recur, consent to release information forms will be reviewed by the clinical supervisor prior to any outside contact on behalf of the clients.
These process of review will be conducted for the next 2 months (May to July) and will be ongoing randomly to ensure accuracy of documentation in accordance with the; 4 Pa. Code 255.5(b) as it apply. |