INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 9, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Two Roads Counseling Services, Inc 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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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
The facility failed to provide an exhaust fan or window in a bathroom as observed during the December 9, 2016 licensing inspection.
The third floor men's bathroom was observed to have an inoperable exhaust fan.
These finding were reviewed with facility staff during the inspection process.
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Plan of Correction
The Program/Facility Director has asked the landlord to fix or replace the broken exhaust fan in the men's restroom on 12/12/16.The Program/Facility Director will check all fans on a weekly basis to ensure that all mechanisms are in functional order. |
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
The facility failed to document that clients were notified of their rights in two of two client records reviewed on December 9, 2016.
Two patient records were reviewed. There was no documentation that the clients were informed of the right to retain civil rights and liberties; clients had the right to inspect their own record; portions may be temporarily removed; reason for removal would be documented in the record; client had a right to appeal the decision to remove portions of the record; client had a right to request the correction of inaccurate, irrelevant, outdated or in complete information in their record and that they had the right to submit rebuttal data or memoranda to their own record in client records # 1 and 2.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program/Facility Director will change the client rights section in our manual. This revision also will be circulated to all employees,volunteers and consumers. An additional client rights form will be created and signed by all current and new clients, to ensure the clients are informed of this change. Staff will be required to attend an in-house training regarding confidentiality and client rights on 1-13-17. This training will be provided by the facility/program director at the Brookville office and will address all intricacies of 709.30, and pa code 255.5. The policy addendum will be reviewed by all staff at the training in addition, the facility/program director will perform random, monthly chart audits to ensure that this policy change is being reflected by all staff. |