INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Peniel Drug & Alcohol Residential Treatment Facility 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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705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to store all cooking utensils in a clean enclosed area. Cooking utensils in the kitchen were being stored in a bin that was not enclosed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The corrective action was completed on July 26, 2022, the day of the site inspection. The cooking utensils in the kitchen were removed from the open bin and then moved to a clean enclosed area. The cooking utensils are now stored in drawers that are clean and enclosed. The culinary director will oversee that the sanitary procedures are maintained of consistently cleaning the cooking utensils after usage and then storing them in the clean enclosed drawers. |
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
Based on one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record # 5. Client # 5 was admitted on September 16, 2021 and was discharged on January 3, 2022. An email was sent to a family member on November 16, 2021 and a fax was sent to a county agency on January 11, 2022 without a valid informed and voluntary consent from the client for the disclosure of information.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the July 20, 2021 annual licensing inspection.
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Plan of Correction
As it relates to 709.28 (c) Confidentiality, client #5, there was an email sent to a family member and a fax sent to a county agency without a valid consent form.
The corrective action was completed on July 26, 2022, the day of the site inspection. The Clinical Supervisor met with employee #4 and rehearsed with them the policy for communication with individuals who do not have a valid consent. In addition, the Clinical Supervisor sent a memo to all clinical staff reminding them of the 709.28 (c ) regulation as it relates to confidentiality, to obtain a valid informed and voluntary consent from the client for the disclosure of information. The Clinical Supervisor will give oversight to clinicians to ensure this confidentiality regulation is being followed.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of the facility policy and procedure manual and conversation with facility staff, the facility did not provide documentation of inspections of the drug storage area. Per the facility policy, inspections are to be conducted monthly, but no documentation was provided at the time of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The corrective action was completed on July 26, 2022, the day of the site inspection. The Clinical Supervisor reviewed with the Medical Liaison staff the established policy for medication control 709.32 (c). A memo was also sent to the medical liaison which outlined the procedure for ensuring the monthly inspection and documentation of the medication and storage areas. The Clinical Supervisor will give oversight by making periodic checks to ensure that this policy is being maintained. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
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Observations
Based on a review of client records, an obituary for client # 5 was documented in the client record however, an unusual incident report was not filed with the department.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In response to the citation 709.34 (c) (2) Reporting of Unusual Incident, the Clinical Supervisor filed a written Unusual Incident Report, reporting the death of former client 760-712. The Clinical Supervisor will give oversight to ensure that unusual incident reports are filed within 3 business days following an unusual incident involving death or serious injury due to trauma, suicide, medication error or unusual circumstances. |