INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 15, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management Inc. was found to be not 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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705.28 (a) (1) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on March 15, 2017, the rear exit route from the building, which passes through an interior space, was not properly illuminated.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
On 3/20/17, Mark Sigmund talked to the tenants next door who control the lights for the rear exit route from the building which wasn't illuminated on 3/15/17, and requested that they keep the interior space for the rear exit route properly illuminated 24/7. On 3/20/17, Mark Sigmund also located the light switch which illuminates the interior space for the rear exit route from the building. The switch for the the interior space which wasn't illuminated on 3/15/17, is located on the wall near the very front of the main interior space, and is accessible at all times to RAW Staff. On 3/30/17, Mark Sigmund showed all RAW staff members the light switch for properly illuminating the interior space for the rear exit route from the building. On 3/30/17, Kate Zelinski and Jessica Rottinger agreed to conduct a walk through of the emergency exit route daily at 9 AM prior to the arrival of their clients and again at 1 PM, to make sure the rear exit route is properly illuminated. During these times, they will turn on the lights if the tenants next door fail to keep the exit route properly illuminated. Mark Sigmund and Lauren Smith agreed to conduct a walk through the rear exit route daily at 4:45 PM and and 8:15 PM, to make sure the rear exit route is properly illuminated, and agreed to turn on the lights if the tenants next door fail to keep the exit route properly illuminated. Both daily walk throughs began on 4/3/17 |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
During a physical plant inspection conducted on March 15, 2017, it was observed that there were demographic face sheets with client identifying information that were on the desk in group room B. Additionally, a file cabinet that was unlocked in group room B contained group roster sheets with clients full names listed on the forms.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Mark Sigmund reviewed § 709.28. Confidentiality. (b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases, with all NE RAW Staff during our weekly staff meeting on March 21, 2017, and conducted a follow-up review with each clinician during bi-weekly supervision 3/28/17. Mark Sigmund will review 709.28 monthly during both individual supervision and group supervision, and also conduct random monthly walk-throughs, to ensure that staff are complying with 709.28. |
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 a review of client records conducted on March 15, 2017 the facility utilized a form titled "Financial Responsibility Agreement & Authorization to Release Information to Insurance Company" in client records #1, 3, 5, 6 & 7.
This form authorizes the release of the client's medication, and dates of attendance as well as "other pertinent information in order for my insurance company to grant authorization of my attendance" which exceeds the limitations imposed at 255.5.
Client # 1 was admitted on 1/12/17 and was an active client at the time of the inspection.
Client # 3 was admitted on 2/24/17 and was an active client at the time of the inspection.
Client # 5 was admitted on 6/15/16 and was discharged on 8/12/16.
Client # 6 was admitted on 8/11/16 and was discharged on 11/10/16.
Client # 7 was admitted on 7/19/16 and was discharged on 9/27/16.
This is a repeat citation.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Mark Sigmund sent out an email to staff on 3/15/17 letting staff know to discontinue use of the faulty financial release form which violated limitations imposed at 255.5, and to make sure they are using the compliant financial responsibility which had been revised in 2016, and is compliant with 255.5. In addition, he removed the non-compliant form from the copy machine on 3/16/17, where all the forms are saved, and instructed staff to destroy any non-compliant financial responsibility forms during RAW staff meeting on 3/21/17. In addition, on 3/21/17, Mark Sigmund instructed staff to review current open charts, and replace any non-compliant financial responsibility forms with the compliant form, and have their clients sign the new compliant form. Client #1, signed the correct form on 3/28/17, which was placed in their chart. Client #3 signed the correct form on 3/30/17, which was placed in their chart. Mark Sigmund will review all RAW charts monthly, to ensure that no non-compliant forms are being used. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Client records were reviewed on March 15, 2017. The facility failed to document that the client was offered a copy of the consents to release information, indicated below, in client records, #3, 6 & 7.
Client #3 was admitted on 2/24/17 and was an active client at the time of the inspection. Consent to releases to a funding source, a family member, and a lab, all dated 2/24/17.
Client #6 was admitted on 8/11/16 and was discharged on 11/10/16. A consent to release to a family member, dated 8/31/16.
Client #7 was admitted on 7/19/16 and was discharged on 9/27/16. A consent to release to an individual, dated 7/19/16.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Mark Sigmund sent out an email to all NE RAW Staff members on the night of 3/15/17, instructing them to make sure they are documenting that their clients are offered a copy of the consents to release information. Mark Sigmund conducted a staff training on 3/28/17 on the proper completion of documentation, specifically, training staff to document that their clients are offered a copy of the consents to release information. Mark Sigmund instructed staff on 3/28/17 to check and make sure that all their active clients were offered a copy of consents to release information, and that this was documented in their charts. He instructed RAW Staff to follow-up with any active clients who may not have been offered a copy of the release of information, and to offer them copies, and to document this in the charts. On 3/27/17, Client #3 was offered a copy of consent to release to a funding source, a family member, and a lab, and this was documented in their chart. Mark Sigmund will conduct monthly chart audits starting April 7, 2017, and check to make sure clinicians are documenting that their clients were offered a copy of the consents to release information. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Client records were reviewed on March 15, 2017. The facility failed to update the treatment plan every 60 days in client records, #2, 4 & 6.
Client #2 was admitted on 11/18/16 and was an active client at the time of the inspection. A comprehensive treatment plan was created on 11/22/16; a treatment plan update was due by 1/22/17 but was not documented until 2/23/17.
Client #4 was admitted on 9/29/16 and was discharged on 12/8/16. A comprehensive treatment plan was created on 10/3/16; a treatment plan update was due by 12/3/16 but was not documented at the time of the licensing inspection.
Client #6 was admitted on 8/11/16 and was discharged on 11/10/16. A comprehensive treatment plan was created on 8/16/16; a treatment plan update was due by 10/16/16 but was not documented at the time of the licensing inspection.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Mark Sigmund conducted a staff training on proper completion of documentation on 4/4/17, specifically training staff on the proper completion of treatment plans and treatment plan updates. Mark Sigmund instructed RAW staff on 4/4/17 during the training, to make sure they are completing treatment plan updates every 60 days. Mark Sigmund will hold another documentation training on April 11, 2017, and will again specifically review proper treatment planning and instruct staff to complete treatment plan updates 60 days from the initial comprehensive treatment plan. Mark Sigmund will conduct monthly chart Audits beginning 4/7/17, and will randomly select 5 charts from each RAW clinician monthly, and make sure all RAW clinicians are completing treatment plan updates every 60 days from the initial comprehensive treatment plan, and implement corrective action if staff fail to properly complete treatment plans and treatment plan updates. Mark Sigmund will follow-up each RAW clinician on the proper completion of documentation during bi-weekly supervision beginning 4/11/17, and continue to train staff on the proper completion of treatment plans, and treatment plan updates. |