INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, RHD Family House 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The July 2015 through June 2016 fire drill record was reviewed during the presubmission process, as well as the day of the inspection. It was discovered that the facility had not conducted a fire drill during the facility's sleeping hours at least once during the previous 6 months. The facility's sleeping hours were confirmed to be from 10:30 pm to 6:00 am. The last documented fire drill during sleeping hours was conducted on 11/18/15 at 1:00 am.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Family House Norristown conducted all fire drills according to licensing regulations; however, failed to document whether a drill was conducted in the am or pm. Quality Assurance Analyst will conduct training with all ADLs to ensure documentation of fire drills incorporates the precise time of the drill, including whether it was conducted in the am or pm hours. Interim Director and/or Office Manager will audit the Fire Drill logbook for compliance at least quarterly. |
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 client records, #1, 4, 9, and 10. Additionally, client records, #4 and 5 had consent to release forms that were missing the specific information to be released, the purpose of the disclosure, and/or the expiration date of the consent form.
Client #1 was admitted on 01/26/2016 and was still an active client at the time of the inspection. There was documentation that a weekly report was made to the local court system on 03/09/2016; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #4 was admitted on 05/16/2016 and was still an active client at the time of the inspection. There was documentation that a facsimile was sent to a doctor's office on 05/16/16; however, there was no proper consent to release information form signed by the client prior to disclosure. Additionally, there was a consent to release form signed and dated on 07/15/16 to a doctor's office, but the consent failed to include an expiration date.
Client #5 was admitted on 12/21/2015 and was discharged on 06/17/2016. The following six consent to release information forms, all signed and dated on 12/21/15, were found to have missing components: a consent form to another treatment provider did not include the expiration date; two separate consent forms to different outside agencies did not include the specific information to be disclosed; a consent form to a doctor's office and a consent form to a government agency did not include the specific information to be disclosed and the expiration dates; and a consent form to another treatment provider did not include the specific information to be released, the purpose of the disclosure, and the expiration date.
Client #9 was admitted on 01/14/2016 and was discharged on 02/13/2016. There was documentation that phone contact was made to the client's primary care physician on 01/26/16; however, there was no proper consent to release information form signed by the client prior to disclosure.
Client #10 was admitted on 10/24/2015 and was discharged on 12/01/2015. There was documentation that urinalysis tests were conducted and the results were received on 11/2/15, 11/4/15, 11/9/15, 11/16/15, 11/23/15, and 11/30/15; however, there was no proper consent to release information form signed by the client prior to disclosure.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Standard intake packets of Consent Forms have been collated to include all standard consents that are signed upon client intake, and additional consents to be completed as applicable for each client. Staff who handle intake have been trained on the proper and appropriate manner in which consents are to be completed, including information that can be disclosed and the purpose of disclosing the information. Office Manager and Interim Director will conduct monthly chart audits to ensure compliance.
Client #1 signed an applicable consent form, including information to be released and purpose of releasing the information, regarding legal court system in June of 2016.
Client #4 ? all appropriate consent forms, including information to be released and purpose of releasing the information, are now signed with applicable expiration dates.
Clients #5- #9 - #10 are no longer in treatment so consent forms cannot be signed by the client.
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709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of patient records, it was discovered that on 02/13/2016, the facility had requested police and ambulance personnel assistance at the facility to assist with a crisis that Patient #9 (an active patient, at that time) had been having. Ultimately, the patient was transported to the local crisis/emergency center via ambulance. The facility subsequently discharged the patient on 02/13/2016 as the patient was admitted to the emergency center. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory 3 business day timeframe.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Quality Assurance Analyst will provide training to Interim Director, who assumed the position as of July 12, 2016, regarding reporting requirements for all incident reports, including events requiring the presence of police, file, or ambulance personnel. Training will also include where incident reports are filed, and will conduct an audit of all incident reports at least twice annually. |