INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17-18, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitation Services, Inc. was found to be not 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) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facilty's fire drill record, the facility failed to indicate whether the fire alarm or smoke detector was operative during fire drills on October 29, 2016, June 26, 2017 and September 27, 2017.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
An internal training will be held for all Youth Care Staff to review the requirements of completing the fire drill log correctly. Upon completion, a certificate will be filed in the employee's training file. Compliance of this POC will be monitored through periodic record checks by the Youth Care Supervisor, Treatment Director, and the Executive Director. |
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
Seven client records were reviewed on October 18, 2017. The facility failed to document a valid consent to release information form in client records #1-7. The purpose of a consent to release information, to a local government agency, was incorrectly listed as " drug testing procedures " .
Client #1 was admitted on 4/4/17 and was an active client at the time of the licensing inspection. The consent to release information to a government agency was dated 4/4/17.
Client #2 was admitted on 5/31/17 and was an active client at the time of the licensing inspection. The consent to release information to a government agency was dated 5/31/17.
Client #3 was admitted on 7/17/17 and was an active client at the time of the licensing inspection. The consent to release information to a government agency was dated 7/17/17.
Client #4 was admitted on 2/7/17 and was discharged on 5/5/17. The consent to release information to a government agency was dated 2/7/17.
Client #5 was admitted on 3/9/17 and was discharged on 7/14/17. The consent to release information to a government agency was dated 3/9/17.
Client #6 was admitted on 3/2/17 and was discharged on 8/25/17. The consent to release information to a government agency was dated 3/2/17.
Client #7 was admitted on 5/22/17 and was discharged on 10/8/17. The consent to release information to a government agency was dated 5/22/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The typographical error in the confidentiality release was corrected at the time it was identified. The client files identified in this POC will have new consent for release of information forms reflecting the local police municipality for the purposes of releasing client information permitted by PA Law 255.5. Compliance of this plan of correction will be overseen through periodic record checks by the Clinical Supervisor. |