INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 20 - 21, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on July 14, 2006.
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Plan of Correction
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Tubs in some of the apartments used by the clients did not have non skid surfaces. There must be slip-resistant surfaces in all bathtubs and showers.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
No apartments/bedrooms were found to be equipped with devices which would alert hearing impaired persons in the event of an emergency. At least one living area must be so equipped.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
No fire drill was documented for June 2005. It was noted that two were conducted in May 2005 with one being done on May 31. A fire drill must be documented for each calendar month.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Inconsistent documentation of fire drills during sleeping hours was presented at the inspection. At least one fire drill must be documented during sleeping hours every six months.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Documentation presented did not clearly demonstrate that the fire alarms were activated and operable during each fire drill. A fire alarm or smoke detector must be activated during each drill unless the Department has approved an alternative procedure in writing.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The written policy incorrectly addresses the duty to warn for threats against a third party citing the Tarasoff (California case law) precedent.
Two statements on the consent to release information form used by the agency were incorrect. One statement incorrectly addresses the client's right of revocation. The consent need not be revoked in writing . A verbal revocation must be accepted and should then be documented by the staff who was informed by the client of their desire to revoke the consent to release information. The second statement which is incorrect is the statement at the bottom of the form which states that "..in certain limited circumstances I may be denied treatment if I do not sign a consent form". The requirement of the law is that the consent be informed and voluntary.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Content noted in the PCPC continued stay documents contained details related to the client's treatment which exceeded the limitations imposed at 4 Pa. Code subsection 255.5(b). Comments exceeded those limitations in records # 1, 2 and 3. One file (#1) included a consent to release information form which did not identify the specific information to be released.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
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Observations
Medication administration records did not include complete documentation . Start and stop dates were not entered for medications prescribed. Inconsistent documentation regarding missed doses of medication was found in the records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Consents to treatment were not documented in any of the records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Preliminary treatment plans were not documented in files reviewed. A Preliminary Treatment Plan should be based upon information derived from the initial interview. The purpose of the preliminary treatment plan is to provide some basic goals to engage the client in treatment during the period before the comprehensive treatment plan is developed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Content on treatment plan updates did not consistently address progress on the stated goals of the treatment plan. (Files #1, 3 and 4). The treatment plan update should include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(12) LICENSURE Work as treatment
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Work therapy was not documented on treatment plans reviewed. Verification must be documented that work done by the client at the project is an integral part of his treatment and rehabilitation plan. The one exception: Clients cleaning of personal living space. Any duties assigned the client other than the cleaning of personal living space must be addressed in the treatment plan with an individualized goal.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |