INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Family A.C.T.S. Incorporated 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 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure the safety and well-being of clients, staff and visitors as evidenced by the following:There was not an operable smoke detector located in the basement. This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Project Director/Facility Director will ensure that an operable smoke detector is placed in the basement area of the physical plant immediately. |
705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure the safety and well-being of clients, staff and visitors as evidenced by the following:There was not a portable fire extinguisher with a minimum of an ABC rating located in the basement.This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Project Director/Facility Director will ensure that a certified and operable fire extinguisher with a minimum rating of ABC is placed in the basement area of the physical plant. |
709.28 (a) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
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Observations
Based on the review of the facility's policy and procedures manual, the facility failed to develop a policy and procedure which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The current procedure includes "in the event that a consent to release confidential information arises during a telehealth session, said release will be completed as normal with "verbal consent telehealth" in place of the client ' s signature". Verbal consents are not valid for consents to release information. The policy and procedure manual was reviewed on July 21, 2021.This finding was reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Project Director/Facility Director will ensure that all policy and procedures comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The current procedure that includes "in the event that a consent to release confidential information arises during a telehealth session, said release will be completed as normal with "verbal consent telehealth" in place of the client's signature", will be removed from the Policy and Procedure manual, as verbal consents are not valid for consents to release information. |