INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab After Work 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) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
The fire drill logs were reviewed on February 26, 2014. The time period reviewed was February 2013 through January 2014. The facility did not document any alternate exits used during fire drills. The front door exit was the exit route used during every fire drill that took place during this time period.
The findings were confirmed with the site director prior to the exit interview.
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Plan of Correction
Effective immediately (today, 3/25/14), Site Director will conduct unannounced fire drills at least once per month. Site Director will maintain written fire drill record, including the date, time, amount of time it took for evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered, and whether the fire alarm/smoke detector was operative. Site Director will prepare alternate fire drills in accordance with 705.28(d)(5). Exit routes used will be documented appropriately in fire drill log.
Site Director will monitor fire drills and fire drill log monthly to ensure ongoing compliance. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of the client records, the facility released information that exceeded what was permissible by 4Pa. Code 255.5(a)(6).
The findings include:
Five client records requiring consent to release information were reviewed on February 26, 2014. One of five client records reviewed contained released information that exceeded that which is permissible to be released by 4Pa. Code 255.5(a)(6), specifically record # 3.
The findings include:
Client #3 was admitted to treatment on October 2, 2013 and discharged on February 7, 2014. Client record #3 contained three letters dated 10/3/13, 12/2/13, 12/12/13, and 2/10/14 stating the client was in a drug and alcohol treatment program and the client ' s course in treatment; however the letter did not identify the recipient of the letter or the purpose for the release of information. Additionally, since there was no identified recipient or listed purpose included on the letter it was not possible to determine that a valid consent to release information had been completed.
The findings were confirmed with the site director prior to the exit interview.
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Plan of Correction
Site Director will conduct a training on Confidentiality with staff members during weekly staff meeting by 4/15/14. During this meeting, Site Director will review regulations and policies regarding client confidentiality, specifically 4Pa. Code 255.5(a)(6). Site Director will perform random monthly chart audits in order to monitor compliance with confidentiality regulations. |