INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, R&D Center LLC 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
Based on the review of the April - December 2023 fire drill logs, the facility failed to include the amount of time it took for evacuation, the exit route used, the number of persons in the facility and whether the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Correction has been made to the fire drill procedure and subsequent logs. "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" has been added.
Executive Director is responsible for continued compliance of this policy and procedure.
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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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in eight of eight applicable records reviewed. The client records did not include a consent form to the funding source. Staff confirmed billing had occurred.
Client #1 was admitted on September 5, 2023 and was still active at the time of the inspection.
Client #2 was admitted on October 2, 2023 and was still active at the time of the inspection.
Client #3 was admitted on October 23, 2023 and was still active at the time of the inspection.
Client #5 was admitted on August 31, 2023 and discharged on November 13, 2023.
Client #6 was admitted on September 5, 2023 and discharged on December 4, 2023.
Client #7 was admitted on July 25, 2023 and discharged on November 9, 2023.
Client #8 was admitted on July 31, 2023 and discharged on November 27, 2023.
Client #9 was admitted on August 21, 2023 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
Correction has been made. A new tab for consent for funding source has been added to our Electronic Records Software and all subsequent clients have signed this consent.
Admissions Director is responsible for ensuring this policy is completed. Monthly chart audits will ensure continued compliance.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a purpose of disclosure on the informed and voluntary consent forms in five out of nine records reviewed.
Client #1 was admitted on September 5, 2023 and was still active at the time of the inspection. The consent form was dated September 5, 2023 to a family member.
Client #2 was admitted on October 2, 2023 and was still active at the time of the inspection. Two consent forms dated October 2, 2023 and November 7, 2023 were to family members.
Client #4 was admitted on July 31, 2023 and discharged on October 4, 2023. A consent form dated July 28, 2023 was to a family member.
Client #5 was admitted on August 31, 2023 and discharged November 13, 2023. A consent form dated August 17, 2023 was to a family member.
Client #6 was admitted on September 5, 2023 and discharged on December 4, 2023. A consent form dated August 24, 2023 was to an emergency contact.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
This correction has been made. All consents now include the purpose of the consent.
Admissions Director is responsible for ensuring this procedure is completed. Monthly chart audits will ensure continued compliance.
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709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of client records, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in nine out of nine records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This correction has been made. The Clients Rights form in the Sunwave Electronic Medical Records have been updated to include all rights identified in PA code 709.30. The hard copy, that is given to clients upon admission, in the welcome packet has been updated to be in compliance as well.
Clinical Director will monitor to ensure continued compliance. Monthly chart audits will ensure that this policy and procedure is compliant with 709.30.
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709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to include type and frequency on the client's individual treatment and rehabilitation plan in nine out of nine records reviewed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Correction has been made. All subsequent treatment plans have been developed in compliance with PA code 709.20.
Clinical Director audits charts monthly to ensure continued compliance.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information according to the facility's policy and procedures manual in five out of five applicable records. The manual states follow-up is to be completed seven days following discharge.
Client #4 was admitted on July 31, 2023 and discharged on October 4, 2023.
Client #5 was admitted on August 31, 2023 and discharged on November 13, 2023.
Client #6 was admitted on September 5, 2023 and discharged on December 4, 2023.
Client #7 was admitted on July 25, 2023 and discharged on November 9, 2023.
Client #8 was admitted on July 31, 2023 and discharged on November 27, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Correction has been made. All subsequent clients have had follow up phone calls within 7 days of discharge. All follow ups are documented in Sunwave EMR.
Executive Director is responsible for ensuring this policy is compliant. Monthly chart audits will ensure continued compliance.
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