INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 11, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Providence Living LLC dba Providence Treatment 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of the facility's March 2020 through February 2021 fire drill log, the facility failed to conduct unannounced fire drills at least once a month for the months of September 2020 through February 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The office was temporarily closed due to COVID and no staff members or clients were present at this premise form September 2020 to February 2021.
The staff member will resume in person fire drill starting March 2021 to ensure the egress route is clear.
COO will perform monthly fire drill audit to ensure monthly fire drill is performed. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on consent to release information forms in one of seven client records reviewed.
Client # 5 was admitted to the outpatient level of care on May 4, 2020 and was still active at the time of inspection. A release of information form to a doctor was signed and dated by the client on September 8, 2020 and the form did not document the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client #5 specific information to be disclosed is now clarified and identified on his ROI as of 3/22/2021.
The facility director provided training to all staff members in use of release of information form on 3/12/2021. Attendance to this training was obtained and filed.
The facility director will perform quality check on ROI as part of monthly internal audits. |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
|
Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on consent to release information forms in one of seven client records reviewed.
Client # 5 was admitted to the outpatient level of care on May 4, 2020 and was still active at the time of inspection. A release of information form to a doctor was signed and dated by the client on September 8, 2020 and the form did not document the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client #5 purpose of disclosure on his ROI dated 9/8/2020 was clarified and identified as of 3/22/2021.
The facility director provided training to all staff members in use of ROI form on 3/12/2021. Attendance to this training was obtained and filed.
The facility director will perform quality check on ROI as part of monthly internal audits. |