Observations
The fire drill record log was reviewed on December 21, 2016. The log was reviewed for the period of June 2016-November 2016. There was no documentation that a fire drill was conducted in July 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Oversight of 7/2016 fire drill was a result of unexpected staff vacancy and to avoid this in the future, 2 additional staff onsite (PD and Lead Counselor) in addition to identified RISK lead will participate in Penn Safe Training on 1/10/2017 to increase number of staff trained to facilitate fire drills at this location.
An additional internal audit to ensure fire drill is scheduled or has occurred will be reviewed the 15th of each month by PD to ensure safe practices on a consistent basis. |
Observations
Ten client records were reviewed on December 21, 2016. The facility failed to obtain an informed and voluntary consent in five of ten client records reviewed.
Client #1 was admitted on September 26, 2016 and was still an active client at the time of the inspection. The client record did not contain documentation of two consents for two different funding sources. The client record contained documentation that patient identifying information was released to the funding sources on October 19, 2016 and October 20, 2016.
Client #2 was admitted on October 3, 2016 and was still an active client at the time of the inspection. A consent to release information form, dated September 26, 2016 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment." The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on October 5, 2016, October 24, 2016 and December 7, 2016.
Client #4 was admitted on October 4, 2016 and was still an active client at the time of the inspection. A consent to release information form, dated October 4, 2016 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment." The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on November 1, 2016.
Client #5 was admitted on August 29, 2016 and was discharged on October 14, 2016. A consent to release information form, dated August 17, 2016 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment." The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on October 14, 2016 and October 21, 2016.
Client #10 was admitted on August 24, 2016 and discharged on December 2, 2016. A consent to release information form, dated August 22, 2016 to a criminal justice agency, did not allow for the consent to be revoked "until there has been a formal and effective termination or revocation of my release from confinement, probation, or parole, or other proceeding under which I was mandated into treatment." The client record contained documentation indicating that the facility released patient identifying information to the criminal justice agency on September 20, 2016 and December 2, 2016.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In regard to Client 1-Facility staff participated in confidentiality review related to multiple funding sources during team meeting on 1/2. Client is currently pending discharge from program due to loss of contact. Should client respond to pending discharge letter and re-engage, an updated consent for funding sources will be completed.
System wide the Criminal Justice Consent has been updated in our ECR system. For Client 2, Client 4, and all current active clients enrolled prior to 11/30/2016 with a Criminal Justice Consent in place an updated consent form is to be completed with clients by their primary counselors on 1/16/2017. This has been reviewed in team meeting on 1/2/2017, as well as, each staff has received a caseload list from PD of clients this citation impacts to make necessary adjustments. |