INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sarah Jane Bentley Foundation 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
Based on the review of fire drill logs from January 2022 - December 2022, the facility failed to document on each log whether the fire alarm or smoke detector was operative, and which exit route was used during the drill. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
I, the director will make sure that voice command for all fire drill will be the response for all fire drills moving forward, The foundation can not use pull alarm or smoke detector, because this is a share space with multiple offices in this building. |
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.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form prior to releasing information in four out of five records reviewed. The client records did not contain a release form for the funding source. Staff verified that billing has occurred.Client #2 was admitted on August 1, 2022 and was still active at the time of the inspection.Client #3 was admitted on August 2, 2022 and was still active at the time of the inspection.Client #4 was admitted on August 3, 2022 and was still active at the time of the inspection.Client #5 was admitted on August 3, 2022 and was still active at the time of the inspection.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
I, the director of the SJBF, will follow all documentation that is needed for all incoming client in this facility, for funding and releases that is require for intake. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form, as the forms were missing the person, agency or organization to whom disclosure is made, in five out of five records reviewed. Client #1 was admitted on August 4, 2022 and was still active at the time of the inspection. There was one form missing the required information.Client #2 was admitted on August 1, 2022 and was still active at the time of the inspection. There were three forms missing the required information.Client #3 was admitted on August 2, 2022 and was still active at the time of the inspection. There were three forms missing the required information.Client #4 was admitted on August 3, 2022 and was still active at the time of the inspection. There were three forms missing the required information.Client #5 was admitted on August 3, 2022 and was still active at the time of the inspection. There were three forms missing the required information.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
I, the director of the SJBF, will follow all documentation that is needed for all incoming client in this facility, for funding and releases that is require for intake. |
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 the review of client records, the facility failed to document a completed consent to release information form, as the forms were missing the specific information that could be disclosed, in five out of five records reviewed. Client #1 was admitted on August 4, 2022 and was still active at the time of the inspection. There was one form missing the required information.Client #2 was admitted on August 1, 2022 and was still active at the time of the inspection. There were three forms missing the required information.Client #3 was admitted on August 2, 2022 and was still active at the time of the inspection. There were three forms missing the required information.Client #4 was admitted on August 3, 2022 and was still active at the time of the inspection. There were three forms missing the required information.Client #5 was admitted on August 3, 2022 and was still active at the time of the inspection. There were three forms missing the required information.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
I, the director of the SJBF, will follow all documentation that is needed for all incoming client in this facility, for funding and releases that is require for intake. |
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 the review of client records, the facility failed to document a completed consent to release information form, as the forms were the purpose of disclosure, in five out of five records reviewed. Client #1 was admitted on August 4, 2022 and was still active at the time of the inspection. There was one form missing the required information.Client #2 was admitted on August 1, 2022 and was still active at the time of the inspection. There were three forms missing the required information.Client #3 was admitted on August 2, 2022 and was still active at the time of the inspection. There were three forms missing the required information.Client #4 was admitted on August 3, 2022 and was still active at the time of the inspection. There were three forms missing the required information.Client #5 was admitted on August 3, 2022 and was still active at the time of the inspection. There were three forms missing the required information.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
I, the director of the SJBF, will follow all documentation that is needed for all incoming client in this facility, for funding and releases that is require for intake. |