INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 16, 2019 through October 17, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Penn Foundation 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to identify, on their written fire drill log, which exit route was used during drills conducted in January, February, March, and April 2019. This was discovered during the review of the January 2019 through October 2019 fire drill logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Program Director will educate their persons they supervise on the fire drill log requirements to assure a exit is identified. The Outpatient program director will audit the monthly fire drill logs to assure the exit utilized is identified. |
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 include documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment in every client record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Director revised the client handbook to assure the facility included documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment in every client record reviewed.
The client charts identified who are still active in the program will be provided an updated client handbook by their therapist and sign for this to assure notification that documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment.
The persons who are no longer active in services will be mailed an updated handbook by the designated support staff and over seen by the Outpatient Director. The facility will request the inactive persons to mail back the signed statement that they received the updated versions will be requested by the facility.This assures the facility included documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment. |
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
The facility failed to include documentation verifying the written acknowledgement by clients that they had been informed of their right to have portions of their record removed prior to review and the reasons for removal shall be documented in the client record in every client record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Director revised the client handbook to assure the facility included documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment in every client record reviewed.
The client charts identified who are still active in the program will be provided an updated client handbook by their therapist and sign for this to assure notification that documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment.
The persons who are no longer active in services will be mailed an updated handbook by the designated support staff and over seen by the Outpatient Director. The facility will request the inactive persons to mail back the signed statement that they received the updated versions will be requested by the facility.This assures the facility included documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment. |
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
The facility failed to include documentation verifying the written acknowledgement by clients that they had been informed of their right to appeal any decision limiting access to their record in every client record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Director revised the client handbook to assure the facility included documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment in every client record reviewed.
The client charts identified who are still active in the program will be provided an updated client handbook by their therapist and sign for this to assure notification that documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment.
The persons who are no longer active in services will be mailed an updated handbook by the designated support staff and over seen by the Outpatient Director. The facility will request the inactive persons to mail back the signed statement that they received the updated versions will be requested by the facility.This assures the facility included documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment. |
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
The facility failed to include documentation verifying the written acknowledgement by clients that they had been informed of their right to submit rebuttal data or memoranda to their own records in every client record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Compliance Director revised the client handbook to assure the facility included documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment in every client record reviewed.
The client charts identified who are still active in the program will be provided an updated client handbook by their therapist and sign for this to assure notification that documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment.
The persons who are no longer active in services will be mailed an updated handbook by the designated support staff and over seen by the Outpatient Director. The facility will request the inactive persons to mail back the signed statement that they received the updated versions will be requested by the facility.This assures the facility included documentation verifying the written acknowledgement by clients that they had been informed of their right to retain their civil rights and liberties and cannot be deprived of their civil rights solely by reason of treatment.. |