INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Impact Counseling Services, LLC. 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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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire drill record, the facility failed to document alternate exits during fire drills from September 2016 thru August 2017.
All fire drill logs submitted indicated that only the front door was used to exit during the fire drills.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Staff was trained on and all fire drills will now include utilizing the back door entrance and exit as well as the front door for fire drill and exit purposes. Fire drills will be performed at various times of the day as well. |
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 July 18, 2017. The facility failed to document a valid consent to release information form in client record #7.
Client #7 was admitted on 6/5/17 and was discharged on 8/28/17. A consent to release for another treatment provider, dated 6/5/17, did not specify the information to be released.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Project Director trained staff on implementation of consents and making releases valid by marking off all appropriate information to be released to the individual or agency on the release form. Staff were also trained on confidentiality and its limitations. Chart reviews are to be conducted weekly by project director for compliance. |
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
Seven client records were reviewed on September 12, 2017. The facility failed to document the following provision on the client rights form in client records #1-7:
(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.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Project director trained staff on new forms that were revised on 10/1/17. The charts will be checked weekly for compliance via random chart reviews done so by the project director. Old forms were disposed of and new forms are now put into place. Staff was trained on and forms were changed so the patient rights reflect 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. |
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
Seven client records were reviewed on September 12, 2017. The facility failed to document the following provision on the client rights form in client records #1-7:
(4) Clients have the right to appeal a decision limiting access to their records to the director.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Project director trained staff on new forms that were revised on 10/1/17. The charts will be checked weekly for compliance via random chart reviews done so by the project director. Old forms were disposed of and new forms are now put into place.Staff was trained on and patient rights forms were changed to reflect Clients have the right to appeal a decision limiting access to their records to the director.
This information was reviewed with the facility staff during the licensing inspection. |
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
Seven client records were reviewed on September 12, 2017. The facility failed to document the following provision on the client rights form in client records #1-7:
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Project director trained staff on new forms that were revised on 10/1/17. The charts will be checked weekly for compliance via random chart reviews done so by the project director. Old forms were disposed of and new forms are now put into place. Staff was trained on and patient rights forms were updated to reflect that Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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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
Seven client records were reviewed on September 12, 2017. The facility failed to document the following provision on the client rights form in client records #1-7:
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Project director trained staff on new forms that were revised on 10/1/17. The charts will be checked weekly for compliance via random chart reviews done so by the project director. Old forms were disposed of and new forms are now put into place. Staff was trained on and patient rights forms were updated to reflect Clients have the right to submit rebuttal data or memoranda to their own records. |