Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 21, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Colonial House Inc. 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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Observations
Based on the review of the facility ' s policy and procedure manual, the procedure for confidentiality of client identify and records indicates that client records are to be secured in a locked clinical supervisor's office. The facility is currently not accepting clients and moved client records to another inpatient facility within the project. After a physical plant inspection of this facility, it was observed that the client records were being stored in a medical office that multiple employee have access to.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Direct will ensure that the policy and procedure for securing clients records will be changed to state that an identified room (client file room) will be identified and all current client records will be stored in this room. Only clinical staff, Facility Director and Project Director will have access to this room.
It will be the responsibility of the Clinical Supervisor to ensure that all charts are properly stored daily in the client file room and that all charts are accounted for.
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