INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16, 2014 by staff from the Division of Drug and Alcohol Program Licensure. 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) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs and interviews with the project director and facility director, the facility failed to document the completion of monthly unannounced fire drills.The findings include:A review of the fire drill logs was conducted on May 28, 2014. There was no documentation that a fire drill was conducted for the month of December 2013. An interview was conducted with the project director and the facility director on June 16, 2014, which confirmed that there was no fire drill conducted and therefore no documentation of a fire drill in December 2013.
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Plan of Correction
The Facility Director will retrain all facility staff on fire safety and fire drill procedures on 7/15/14. Facility Director will schedule monthly fire drills beginning on 7/21/14 and will monitor fire safety procedures through weekly inspections beginning on 7/21/14. |
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 client records, the facility failed to document an informed and voluntary consent from the client for the disclosure of information, which is to include the purpose of disclosure in two of eleven client records.The findings included:Eleven client records requiring an informed and voluntary consent from the client for the disclosure of information were reviewed on June 16, 2014. The facility failed to obtain an informed and voluntary consent from the client; including the purpose of disclosure in client records # 6 and 7.Client # 6 was admitted into treatment on August 24, 2013 and was discharged on August 29, 2013. A consent to release information to a parent, dated August 24, 2013, did not include the purpose of disclosure.Client # 7 was admitted into treatment on July 19, 2013 and was discharged on September 2, 2013. A consent to release information to a judge's office, dated August 9, 2013, did not include the purpose of disclosure.The Project Director and the Facility Director confirmed the findings.
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Plan of Correction
The Facility Director will retrain staff on appropriate completion of consent to release forms by staff on 7/23/14 and weekly monitoring by the lead counselor to ensure ongoing compliance beginning 7/28/14. |