INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25, 2007 to July 26, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on August 17, 2007.
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Plan of Correction
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705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
The facility failed to consistently document alternate exit routes on all fire drill logs.
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Plan of Correction
The fire drill log is documented according to what exit is blocked therefore all alternative exits are used.
The form will be changed that will require documentation of what alternative exits were used and will include what exit was blocked.
A meeting with the director and the house manager was held on August 1, 2007 discussing this area the form will be completed by August 3, 2007 by the house manager and reviewed by the director to assure compliance. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
The facility failed to consistently document that the fire alarm or smoke detector was set off during each fire drill.
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Plan of Correction
Documentation of the drill procedure will be documented on the Fire Alarm Test Log. There is only one pull alarm that is used for drills. It is located at the back door. This will be documented in the manual as well by the director by August 3, 2007 |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to consistently comply with the limitations on the release of information imposed at 4 Pa. Code Subsection 255.5(b) for specific information disclosed to health and hospital plans, criminal justice entities and/or government officials. On all 4 client records reviewed the Pennsylvania Client Placement Criteria (PCPC) forms that were released to those entities contained information in Dimension 3 that exceeded the limitations imposed by 4 Pa. Code Subsection 255.5(b).
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Plan of Correction
We were not in compliance due to issues that the client has such as self-esteem , impulse control etc. that were documented on the PCPC Demension 3, were cited because these issues might (should) be addressed in treatment plans. Therefore releasing information that should not be addressed on the PCPC.
A review of the pcpc and confidentiality application was held with all clinical staff on August 1, 2007 by the clinical supervisor. All clinical staff will attend this training on the state level again which will allow them to ask questions to clarify 255.5. This will be followed up by the clinical supervisor. Clinical supervisor, and director are responsible for oversight. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
The facility failed to consistently document the client's progress in relationship to the stated goals of the comprehensive treatment plan. In all four client records reviewed updates were completed, but did not consistently include specific information regarding previous goals.
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Plan of Correction
A review with all clinical staff was held on August 1, 2007 to address documention of comprehensive plan goals and how they were met or if they were on going in the treatment plan update. The meeting was held by the clinical supervisor. Follow up on this issue will be completed by the Clinical Supervisor. The counselors and the CS were responsible for the previous goals not being addressed on the new Treatment Plan. |