INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on 03/14-3/15/2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Endless Mountains Extended Care,LLC 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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704.11(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
Based on a review of the facilties staffing schedules, the facility failed to have at least one person on third shift who was CPR and first aid certified.
The hours for third shift runs from 11pm to 7am
This was reviewed with facility staff during the investigation in order for them to bring the facility into compliance immediately.
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Plan of Correction
In accordance with 704.11, the Facility Director will ensure that we have at least one person on each shift, 7 days/week who is CPR certified. On March 18 2019, the Monday following our Friday inspection, employee #11 (our 3rd shift employee) was promptly certified in CPR and First Aid. Employee #11 worked each night to cover third shift along with employee #3 (a certified trained Counselor Assistant) and employee #14 (a certified Counselor) alternating night shifts when the Drug and Alcohol Technician was unavailable. The remainder of our new staff, who were not yet First Aid/CPR certified received certification on Friday April 5, 2019 with an onsite American Red Cross training program that was scheduled in February to cover each new staff member.
As of March 18, 2019, Endless Mountains Extended Care, LLC was in full compliance with the 704.11 Certification regulation - having 1 staff member per each shift, 7 days a week, 24 hours a day.
Facility Director will maintain compliance with a quarterly review of CPR Certificate dates.
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709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
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Observations
Based on a review of personnel records, the facility failed to provide written verification of their degree and/or college transcripts in records, #1-5.
Employee #1 was hired as the project director on 10/12/18.
Employee #2 was hired as the facility director on 10/12/18.
Employee #3 was hired as a counselor on 10/12/18.
Employee #4 was hired as a counselor on 1/9/19.
Employee #5 was hired as a counselor assistant on 1/28/19.
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Plan of Correction
In accordance with 709.26, the Program Director will ensure that copies of all required verification of professional credentials are placed in employee files for all employees.
The Program Director placed a copy of the educational degrees for employees #1, #2, #3, #4 & #5.
Endless Mountains Extended Care was in compliance with 709.26 as of March 18, 2019. Going forward, the Program director will ensure copies of all required verification of professional credentials are retained on their first day of employment and placed in the respective employee file. |
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
Two client records were reviewed on March 15, 2019, the facility failed to document a valid consent to release in client records,#1-2 .
Client #1 was admitted on 02/01/19 and discharged on 03/04/19.
It was observed that the facility disclosed information to a medical provider however, there was no valid consent to release information for this provider.
A consent dated 02/01/19 for a pharmacy did not specify a purpose or the specific information that was being disclosed.
A consent dated 02/01/19 for a family member did not specify information being disclosed.
A consent dated 02/01/19 for probation did not specify a purpose or the specific information that was being disclosed.
Client #2 was admitted on 02/12/19 and discharged on 03/04/19.
It was observed that the facility disclosed information to a medical provider however, there was no valid consent to release information for this provider.
A consent dated 02/12/19 for a pharmacy did not specify a purpose or the specific information that was being disclosed.
A consent dated 02/12/19 for a family member did not specify a purpose or the specific information being disclosed.
A consent dated 02/12/19 for probation did not specify a purpose or the specific information that was being disclosed.
A consent dated 02/12/19 for a friend did not specify a purpose.
These findings were reviewed with the facility staff during the complaint investigation.
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Plan of Correction
In accordance with 709.28, the Clinical Director will ensure that all client consents in active client files were reviewed immediately after intake.
The Clinical Supervisor met with all Clinical Staff and Facility Director to review how a release should be completed with a specific purpose, and specific information to be disclosed. During the meeting code 255.5 was reviewed. In addition, clinical staff were directed to be the only staff members permitted to complete a release of information.
Clients with consents that were not valid or did not contain specific information to be disclosed or a specific purpose for disclosure were removed from their files. The counselors met individually with each client to discuss why they needed to sign new consents with specified information/purpose for disclosure. The new releases, indicating that the client was offered a copy were then signed by each active client.
All current client files were in compliance by Monday 3/18/2019. Going forward, the Clinical Supervisor will conduct chart audits after each new client intake to ensure that patient releases are correctly written and signed. |
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
Two client records were reviewed on March 15, 2019; the facility failed to document that clients were offered copies of their consents in client records,#1-2 .
Client #1 was admitted on 02/01/19 and discharged on 03/04/19.
Consent to pharmacy dated 2/1/19
Client #2 was admitted on 02/12/19 and discharged on 03/04/19.
Consent to probation dated 2/12/19
Consent to pharmacy dated 2/12/19
Consent to family dated 2/12/19
Consent to friend dated 2/12/19
These findings were reviewed with the facility staff during the complaint investigation.
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Plan of Correction
In accordance with 709.28, the Clinical Director will ensure that our each of our consent forms note that a copy of the consent is offered to the client.
The Facility Director revised the release form to indicate their acknowledgement that a copy was offered to the client. The Clinical Director met with clinical staff to review the regulation code. Clinical staff were informed that after they offer a copy of the release(s) to their client, the client needs to note on the release that they were offered a copy. All consents in active client files were reviewed. Between Friday 3-15-19 and Monday 3-18-19, all clients met individually with their counselors. Consents which did not specify by signature that the client was offered a copy of their release(s) were promptly offered one. All active clients refused a copy of their releases and this was documented on each release.
As of Monday 3-18-19, all active clients have correct releases in their files which indicate they were offered a copy. The Clinical Director will conduct a chart audit after each new client admission/intake process - to ensure that patient releases are correctly written and signed.
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