INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, My Sister's Place Thomas Jefferson University 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 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company as there were two fire extinguishers on the fifth floor of the facility that were missing the appropriate tag that documents the date of the last inspection.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The My Sister's Place- Thomas Jefferson University Program will ensure that all Fire Extinguishers are inspected and approved annually by our local fire department and/or fire extinguisher company.
In order to ensure that our fire extinguishers display the appropriate tag that documents the date of the last inspection, our facility will now provide hard plastic tag covers and/or fire extinguisher casings to prevent a reoccurrence of having the inspection tag removed.
This Plan of Correction will be implemented by 03/01/2022. |
711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
711.53. Client records.
(c) Confidentiality.
(2) 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:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on a consent to release information form in one of seven client records reviewed.Client #2 was admitted July 2, 2021 and was active at the time of inspection. A release of information form to a funding source was signed and dated by the client on July 9, 2021; however, the form did not document the specific information to be disclosed.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The My Sister's Place-Thomas Jefferson University Program will document specific information to be disclosed on ALL Consent to Release Information Forms signed by clients.
In order to prevent a reoccurrence of Consent to Release Forms being completing inaccurately, the Clinical Supervisor and Patient Care Manager will review ALL applicable Consent to Release Information Forms to ensure that they are completed in its entirety and signed by the client.
ALL Consent to Release Information Forms will be reviewed by the Clinical Supervisor and/or Patient Care Manager for accuracy upon completion.
This plan of correction will be implemented effective 12/23/2021.
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711.53(c)(3) LICENSURE Copy of Client Consent
711.53. Client records.
(c) Confidentiality.
(3) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of all informed and voluntary consent to release information forms were offered to the client in one of seven client records reviewed.Client #2 was admitted July 2, 2021 and was active at the time of inspection. A release of information form to a funding source was signed and dated by the client on July 9, 2021; however, there was no documentation that a copy of the consent form was offered to the client. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The My Sister's Place-Thomas Jefferson University Program will document specific information to be disclosed on ALL Consent to Release Information Forms signed by clients.
In order to prevent a reoccurrence of Consent to Release Forms being completing inaccurately, the Clinical Supervisor and Patient Care Manager will review ALL informed and voluntary Consent to Release Information Forms completed to ensure that a copy of the form has been offered to the client.
ALL informed and voluntary Consent to Release Information Forms will be reviewed by the Clinical Supervisor and/or Patient Care Manager to ensure that the client has signed acknowledgement that they have been offered or declined a copy of the consent form.
This plan of correction will be implemented effective 12/23/2021.
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