INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29, 2007 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 April 30, 2007.
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Plan of Correction
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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
The facility failed to document a fire drill for November 2006.
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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) 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:
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Observations
The facility failed to correctly complete consent to release information forms in client records # 2, 4, 5, and 6. The purpose listed on the release forms are not consistent with the function of the recipient of the information, and the information listed to be disclosed is exceeds the limitations on the release of information imposed by 4 Pa. Code subsection 255.5.
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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
The facility failed to document work done at the facility by clients as work therapy and there was no documentation that the facility paid the clients for their services. This was evident in client records # 1, 2, and 3.
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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. |