INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, CHMH Services PA LLC DBA Charlie Health 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of submitted inspection documentation, the facility failed to conduct fire drills from October 2021 through June 2022.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Compliance Manager, reviewed DDAP requirements for fire drills for non-residential facilities. A new fire drill log form was created to meet the fire drill documentation requirements as noted in PA Code Chapter 705. A review of the requirement and the new fire drill log form occurred with staff on July 7, 2022. In addition, a fire drill was conducted on July 7, 2022, and will be conducted and documented monthly going forward. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop policies and procedures regarding a client's right to retain their civil rights and liberties as provided by statute and no client may be deprived of a civil right solely by reason of treatment.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The organization's Client Rights Policy at the time of this survey was missing the correct language as noted in the deficiency. Compliance Manager, has revised the current Client Rights Policy and postings to reflect/add the correct language as of 07/08/22. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop policies and procedures regarding a client's right to not be discriminated against based on creed, sex, color, national origin, and marital status.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The organization's Client Rights Policy at the time of this survey was missing the correct language as noted in the deficiency. Compliance Manager has revised the current Client Rights Policy and postings to reflect/add the correct language as of 07/08/22. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop policies and procedures regarding a client's right to inspect their own records, the project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client and reasons for removing sections shall be documented in the record.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The organization's Client Rights Policy at the time of this survey was missing the correct language as noted in the deficiency. Compliance Manager has revised the current Client Rights Policy and postings to reflect/add the correct language as of 07/08/22. |
709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop policies and procedures regarding a client's right to appeal a decision limiting access to their records to the director.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The organization's Client Rights Policy at the time of this survey was missing the correct language as noted in the deficiency. Compliance Manager, has revised the current Client Rights Policy and postings to reflect/add the correct language as of 07/08/22. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop policies and procedures regarding a client's right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The organization's Client Rights Policy at the time of this survey was missing the correct language as noted in the deficiency. Compliance Manager, has revised the current Client Rights Policy and postings to reflect/add the correct language as of 07/08/22. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to develop policies and procedures regarding a client's right to submit rebuttal data or memoranda to their own records
The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The organization's Client Rights Policy at the time of this survey was missing the correct language as noted in the deficiency. Compliance Manager, has revised the current Client Rights Policy and postings to reflect/add the correct language as of 07/08/22. |