INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on February 6, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Passages to Recovery, Inc. 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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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of video footage, and staff and client interviews, the facility failed to maintain the confidentiality of client identity and records.
On January 28, 2024, a facility staff permitted unauthorized visitors access client areas of the facility where the clients were located, as well as client identifying information.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Passages to Recovery requires that all visitors sign in at the front reception area at entry. Upon arrival any individual who is on site for any reason other than a qualified Service Organization continues to be required to remain in the front entry and can not have access to the administrative hallway or residential living area for any reason. This requirement was again review by staff on 2/9/24, with emphasis on sections regarding unauthorized visitors which:
1. " Permits no unauthorized visitors. All visitors are required to be approved by management. Additionally, visitors are required to follow sign-in/sign-out procedures. Visitors and venders must read and sign acknowledgements for confidentiality and the Prison Rape Elimination Act (PREA) upon arrival and before their first entry onto Passages to Recovery property. Approved visitors and vendors who regularly enter Passages to Recovery properties must sign acknowledgments on an annual basis."
2. "Unauthorized visitors will be asked to leave the premises. Refusal to leave the premise may result in local authority action. Staff who permit unauthorized visitors onto the premises will be subject to disciplinary action, including up to termination."
Staff member who permitted this action was immediately suspended at time of incident and terminated shortly after review of camera footage and internal investigation.
Moving forward Facility Manager and Facility Director will be responsible for ensuring compliance with all policy. |
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.
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Observations
Based on a review of unusual incident report documentation and staff and client interviews, the facility failed to accurately and thoroughly report an unusual incident to DDAP.
An incident occurred on January 28, 2024 in which an altercation occurred between staff and a client. The altercation escalated and a staff person permitted unauthorized visitors to access the facility and they threatened violence. The police were called and presented to the facility. The ususual incident report sent to DDAP on January 29, 2024, included information about the altercation that took place and the police being onsite; however, it did not include any mention of unauthorized visitors being given access to the facility or the threats of violence.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Passages to Recovery follows the guidelines as set forth in:
LICENSING ALERT 01-2024
Reporting of Unusual Incidents
which requires the submission of an unusual incident report within 3 business days following the incident. In an effort to submit the report in a timely fashion the staff submitting the report "did not include any mention of the unauthorized visitors being given access to the site or threats of violence."
This was in part due to the staff wanting to complete a timely report without the full completion of an internal investigation in effort to complete a thorough as well as timely report.
Effective 3/25/204, all unusual incident reports will need to be reviewed by senior level leadership Director's level or higher to ensure that the incident is being reported in full and to the best of the Passages to Recovery's staff knowledge at the time of incident. Should additional details of the event be found out, Passages to Recovery will submit documentation either through the ERS system or via email communication.
Moving forward facility management which will include the facility director and facility manager will be responsible for ensuring the timely reporting of unusual incident reports. |