INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 2, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Roxbury was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the facility physical plant inspection and an interview with the facility director, the facility failed to ensure that all fire extinguishers are inspected and approved annually.
The findings include:
During the physical plant inspection, which took place around 9am on February 2, 2016, it was observed that the last time the fire extinguishers were inspected was July 2014. The facility director was interviewed around the same time of the physical plant inspection and she explained the fire extinguishers were inspected but failed to update the service tag on the fire extinguishers.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to comply with applicable standards, the following steps will be undertaken:
At a minimum of once annually, the Director of OP Services and/or the Director of Physical Plant will perform a physical plant inspection to inspect the service tag on all fire extinguishers and to verify that they have been inspected and approved annually.
This has been completed as of 2/8/16.
The Director of Outpatient Services will assume primary responsibility for this task and will monitor its implementation and ongoing practice.
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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
Based on a review of client records, the facility failed to document the purpose of disclosure and what specific information is being release on the informed and voluntary consent forms in one of ten records.
The finding include:
Ten client records were reviewed on February 2, 2016. All were reviewed for informed and voluntary consent forms. The facility failed to document the purpose of disclosure and what specific information is being release on the informed and voluntary consent form for the client's provider dated August 7, 2015 for client #6.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
OP staff were reeducated on 2/11/16 on the requirement of having a fully completed, informed and voluntary, consent from clients for disclosure of information contained in the client record. The Director of OP Services will perform a random audit of 20 charts and the consents contained in each. The results will be reported monthly to the Performance Improvement Committee until a desired compliance rate of 90% or higher is reached for three consecutive months. |