INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Care Center d/b/a 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 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document the amount of time it took for evacuation in the fire drill records from June 2016 through January 2017 which were reviewed during the annual licensing inspection conducted on February 6, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will document the amount of time it took for evacuation in the fire drill records. The form will be updated to prompt the logging of time. This will be completed by 2/28/17. |
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 three of seven client records reviewed during the annual licensing inspection conducted on February 6, 2017.
A consent to release information was not documented for the insurance company and the facility disclosed the client's name and diagnosis when requesting prior authorization for counseling services in the following client records.
Client # 3 was admitted into treatment on August 3, 2016 and discharged on December 6, 2016. The disclosure occurred on August 11, 2016.
Client # 4 was admitted into treatment on September 12, 2016 and discharged on January 6, 2017. The disclosure occurred on October 6, 2016.
Client # 6 was admitted into treatment on August 19, 2016. The disclosures occurred on August 29, 2016 and January 18, 2017. In addition, a urine drug test was submitted to a laboratory for analysis on August 19, 2017 without a consent to release information or a qualified service organization agreement (QSOA).
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 3, 4 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 Feb 28/2017. 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. 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. In addition The CARE Center will be obtaining QSOA agreements with the laboratory that is utilized. In the mean time the appropriate consents will be obtained prior to releasing information to the laboratory. QSOA agreement will be obtaining by 5/1/17 The Clinical Supervisor will continue to review and monitor consents and releases through internal chart reviews and supervision |