INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 28, 2019 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, Conewago- Pottsville 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) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of fire drills from August 2018-August 2019, the facility failed to conduct fire drills on different days of the week as all fire drills were conducted between the 27-30th of each month. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure that fire drills are conducted on different days of the week each month. Each month, the facility director will review the fire drills from the last three previous months to ensue the drills are being conducted on different days of the week. The facility will be in full compliance with this regulation as of 9/9/2019. |
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 record #9. Client #9 was admitted on July 10, 2019 and was still an active client at the time of the inspection. There was documentation that an email was sent to a funding source on July 23, 2019; 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
Client #9 signed a consent to release information form for the funding source on 9/9/2019. The clinical supervisor retrained all clinical staff on proper procedures for consent to release information forms on 9/4/19. The clinical supervisor and facility director will ensure that refresher trainings are conducted on confidentiality and consent forms on a semi-annual basis. The clinical supervisor will audit charts on a weekly basis, which will include ensuring that consent forms are filled out properly for any information that is released. The facility will be in full compliance with this regulation on 9/9/2019. |