INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Adaapt House 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 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection conducted on February 14, 2024 at approximately 10:00 am, the facility failed to maintain slip-resistant surfaces in all bathtubs and showers.There was no slip-resistant surface in the shower stall of the first-floor handicap bathroom.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In accordance with 705.6. The residential facility shall: (4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers. On 2/15/2024, Director of Maintenance ordered slip resistant items for all showers in the facility. Facility received the order, and all showers are slip resistant. Staff will make sure that all non-slip surfaces are in good shape by doing their daily inspection of the unit. If they find the non-slip surface needs to be replaced, they will notify maintenance of the issue in order for it to be replaced. |
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.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on release of information forms in seven of seven client records reviewed.In every client record reviewed, there was a release of information form to a government agency and each form did not include the purpose of the disclosure.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
09.28. 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. On 2/15/2024, the release for the DOC was edited to include the purpose for the release. Clinical Director had a staff meeting on 2/16/24 and gave staff the updated release which included the purpose of the release. Clinical Director will ensure the correct form is being used by completing her weekly and monthly audit of client charts. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to ensure all copies of client consents were offered to the client in seven of seven client records reviewed. In every client record reviewed, there was an authorization to disclose health information consent form and there was no documentation in each record that indicated a copy of the consent was offered to the client. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.28. Confidentiality. (d) A copy of a client consent shall be offered to the client and a copy maintained in the client record. On 2/15/24, a copy of the Authorization to Disclose Health Information is now being offered to the client. Accept/Refuse has now been added to the release. On 2/15/2024, the release for Disclose Health Information was edited to include the Accept/Refuse. Clinical Director had a staff meeting on 2/16/24 and gave staff the updated release which included that the release was offered to the client. Clinical Director will ensure the correct form is being used by completing her weekly and monthly audit of client charts. |