INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on 04/10/2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Discovery House-NC, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
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.
|
Observations
One client record was reviewed on April 10, 2019, the facility failed limit the disclosure of information to what was stipulated on the consent to release information form in client record #1.
Client #1 was admitted on 02/26/15 and discharged on 03/21/16
The consent to release information form to the client's emergency contact, dated 2/24/2015, allowed for the release of the 'location of pt and nature of emergency', however, the facility released the entire client record to this individual.
This finding was reviewed with the facility staff during the complaint investigation.
|
Plan of Correction
The Program Director and Clinical Supervisor will have a mandatory meeting by June 30, 2019 to review the importance of knowing and utilizing 04 Pa code 255.5 and Federal confidentiality regulation 42 CFR. The staff will only disclose the information stipulated in each patient consent to release. The Clinical Supervisor will make sure each staff member only releases what information is permitted by the release prior to releasing the information. The Clinical Supervisor will inform the Program Director of the information to be released so no information is release without the proper consent. This will be completed by June 30, 2019 |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
The facility failed to ensure that facility heaters were permanently mounted or installed. A portable heater was observed in the office of the facility director.
|
Plan of Correction
The Health and Safety Captain will have a meeting with all staff on June 19, 2019 reviewing the importance of not having portable heater in the facility and fire hazards they may cause. Effective immediately all portable heaters will be removed from the facility. The Health & Safety Captain will do compliance checks to ensure there are no space heaters in the facility. The Program Director will do sporadic compliance checks. This will be completed by June 30, 2019 |