INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tradition House 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to provide CPR certification and first aid training so that at least one person trained in these skills is onsite during the project's hours of operation.Staff CPR and first aid certifications and work schedules were reviewed on November 16, 2016. Staff person #5 was scheduled to work the 3rd shift by himself on 10/17, 10/18, 10/25 and 10/26/16. Staff person #5 was recently hired on 9/1/16 as a technician and has not yet completed CPR and first aid training.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and BH Tech Supervisor will ensure all staff have the required CPR training upon hire. BH Tech Supervisor will ensure one staff member is CPR trained on every shift when completing the employee schedule. Staff person #5 received CPR training on 11/6/16. |
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
The facility failed to obtain informed and voluntary consent forms for the disclosure of information contained in the client record in ten of ten client records reviewed on November 16, 2016.Ten client records were reviewed. Ten records required an informed and voluntary consent to release client information. The facility failed to obtain an informed and voluntary consent to release information in client records # 1, 2, 3, 4, 5, 6, 7, 8, 9 and 10.The consent to release information form states that revocation must be in writing. 42 CFR Part 2, Subpart C, subsection 2.31 (a) Required elements, specifies that the following information must be included on the written consent: "(8) A statement that the consent is subject to revocation at any time except to the extent that the program or person which is to make the disclosure has already acted in reliance on it." Therefore, as per 42 CFR, Part 2, Subpart C, subsection 2.31 (a)(8) the consent to release client information form can be revoked by the client at any time and there is no restriction on the manner in which they may revoke it. The facility failed to adhere to the requirements outlined in the federal confidentiality regulations by requiring the clients to revoke consent forms in writing.In addition, consents to release information to criminal justice authorities were observed to include a statement that the consent could not be revoked. There were no court orders mandating treatment documented for these clients and therefore, the consents could be revoked verbally or in writing at any time.These findings were discussed with facility staff during the licensing process.
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Plan of Correction
VP of Clinical Services revised consents on November 28, 2016 to ensure that all consents contain appropriate elements of a valid consent, including acknowledgement that a copy was offered to the client as well as, the ability to revoke consents verbally or in writing. Criminal Justice consent was revised to eliminate statement that consent cannot be revoked. All staff members who deal directly with consents will receive additional training on revisions and completion of consents. Training will be concluded by February 2017. Completion of training will be verified by post test completion and monitored by Human Resource Coordinators.
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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
The facility failed to document that a copy of signed consents were offered to the client in ten of ten client records.Ten client records were reviewed on November 16, 2016. All ten client records included at least one signed consent in which the client was not offered a copy.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consent forms in the current electronic medical record system does not consistently document verification that a client was offered a copy. Administrative Assistant and Counselors are responsible for updating this in EMR. Administrative assistant or counselor will ensure documentation is in the notes section of the chart, indicating that a copy of the consent was offered to each client. All new clients charts will display documentation that an individual has been offered a copy of their consents. In addition, a new EMR will begin to be implemented in January 2017. The Clinical Coordinator will ensure that the new system allows for verification that a client was offered a copy of their consent. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of two client records.Ten client records were reviewed on November 16, 2016. Two of clients reviewed were involuntarily terminated from treatment at the project. Client records # 2 and 3 did not include documentation of a written notification of termination.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When a client is involuntarily terminated, the counselor will document in the notes section of the clients chart, that a copy of the involuntary notification of termination was offered and provided to the client. Lead Counselor and Program Director will ensure that this is occurring with each discharge. This will be added to our chart audit as well, which is conducted by the Lead Counselor and Program Director. |