INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 28, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Care Center dba SPHS Care 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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705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
The facility failed to maintain the outside emergency exit steps with a well-secured handrail, as observed during the annual licensing physical plant inspection conducted on June 28, 2016 at approximately 1:00 PM. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Supervisor will request that the landlord address the handrail concern. The Supervisor will ensure the handrail is well-secured by 9/30/2016. |
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
The facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in two of ten client records reviewed during the annual licensing inspection conducted on June 28, 2016.A consent to release information form was not documented for the funding entity, and the facility director confirmed the facility disclosed the client's name and identifying information during the billing of counseling services provided in client records # 2 and 6. Client # 2 was admitted into treatment on November 2, 2015. Client # 6 was admitted into treatment on January 4, 2016 and discharged on March 6, 2016.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will obtain appropriate Consents to Release Information for client #2, and #6 where obtaining the consents are possible and remains relevant. The Clinical Supervisors will develop and provide a training update of the accurate and appropriate completion of consents to release information by August 1, 2016. Information to be covered will include appropriate type of release, the appropriate release for funding sources, appropriate choice of information to be released; and limitations of 4 Pa. code subsection 255.5, at a minimum. Consents/Releases will be completed every time an individual's insurance changes at the time of the change. This will be completed by August 1, 2016. A check sheet to be completed after an intake will be used to ensure that releases are obtained prior to approving services to be billed. Lastly, when requesting authorization support staff will check for releases to make sure they are up to date prior to requesting authorization. This will be completed by August 1, 2016. The Clinical Supervisor will continue to review and monitor consents and releases through internal chart reviews and supervision. |