INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 1, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Diocese of Harrisburg, PA, 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
Based on a physical plant inspection, the facility failed to provide ventilation in the bathrooms of client rooms # 25 D, 26 D, 27 D, and 28 D. The bathrooms have windows that are not able to be opened and does not have exhaust fans.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director discussed deficiency with landlord, Roman Catholic Diocese, Buildings and Properties. Landlord stated more likely will install exhaust fans in cited rooms due to costs. Time will needed allotted for the ordering of the fans and scheduling for the installation of exhaust fans once they come in. |
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.
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Observations
Based on two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to not exceed the specific information disclosed that the consent allowed in client records # 1 and # 2. Also, the specific information disclosed exceeded 255.5 (a) (6) to an employer in client record # 1.
Client # 1 was admitted on April 7, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on July 28, 2021 to referral source allowed for the release of whether the client is or is not in treatment and the nature of the facility. A correspondence on July 28, 2021 provided information on the client's diagnosis, drug and alcohol history, and mental health history. Also, An informed and voluntary consent from the client for the disclosure of information signed and dated on July 6, 2021 allowed for the release of whether the client is or is not in treatment and the nature of the facility to an employer.
Client # 2 was admitted on April 19, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on July 29, 2021 to referral source allowed for the release of whether the client is or is not in treatment and the nature of the facility. A correspondence on July 29, 2021 provided information on the client's diagnosis, drug and alcohol history, and mental health history.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 27, 2021 licensing inspection
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Plan of Correction
Program Director will have current client #2 execute a revised and corrected version of the Release Form to include releasing specific information reflected on the Release Form. Client #1 has been discharged since the site inspection and cannot be corrected.
The PD will further train and train clinical staff in regards to confidentiality law and restrictions. PD and clinical staff will repeat state confidentiality training to reinforce learning and consistency with state regulation. PD will search and schedule confidentiality trainings via virtual, in-person, or other state approved training.
The PD will continue to conduct quarterly chart audits to ensure Releases are compliant going forward starting November 30, 2021. |