INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 7, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Diakon Child, Family and Community Ministries was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
705.27 (4) (ii) LICENSURE General safety and emergency procedures.
705.27. General safety and emergency procedures.
The nonresidential facility shall:
(4) Provide written procedures for staff and clients to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
|
Observations
Based on a review of employee training records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies as there was no documentation of completion for Employees #3.
|
Plan of Correction
Preparation and submission of this plan of correction is required by State and Federal law. This plan of correction does not constitute admission for purposes of general liability, professional malpractice or any other court proceeding.
The Clinical Director will ensure that all personnel are trained on their assigned duties during emergencies. The training and participation logs will be maintained in the Clinical Director's Office. Training will be completed by August 30, 2016. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of employee training records, the facility failed to ensure that each employee was instructed in the use of the fire extinguisher upon staff employment as there was no documentation of completion for Employee #3.
|
Plan of Correction
Preparation and submission of this plan of correction is required by State and Federal law. This plan of correction does not constitute admission for purposes of general liability, professional malpractice or any other court proceeding.
The Clinical Director will be responsible for instructing all employees in the proper use of fire extinguishers and maintain records validating the dates and names of staff attending each training. This will be completed upon staff hire/orientation and/or within the first 90 days of employment date. Staff # 3 will complete training by August 30, 2016. |
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:
|
Observations
Based on a review of the client records, the facility failed to indicate on an informed and voluntary consent form the name of the agency the information was to be released to as well as the date and signature of the client in client record #4.
In addition, an informed and voluntary consent form to a human service agency that allowed for the treatment attendance and nature of project/services to consumer for the continuity of consumer care and coordination of services was not sign by the client in client record #5.
|
Plan of Correction
The Clinical Director will provide a
training for all clinical staff,
reviewing client confidentiality,
signed informed consent and the
requirements necessary to release
client records by 7/30/16.
|