INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 8, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Familylinks, Inc. 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to document unannounced fire drills at least once per month and include whether or not the smoke detector/fire alarm was operative for each of the fire drills conducted.
The fire drill logs were reviewed during the administrative review that was conducted on March 5, 2019. The period of March 2018 - February 2019 was reviewed. There was no fire drill conducted for the month of July 2018 and the drills conducted in April 2018 and February 2019 did not include documentation if the fire alarm / smoke detectors were operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager reviewed Observation #:P273 with Building Safety Representative. Fire Drills will be conducted monthly at the Banksville Location. Safety Representative will also include documentation if the fire alarm/smoke detectors were operative. A log will be completed for each event by the Building Safety Representative. The Building Safety Representative will keep each drill in a safety binder for review. These findings have been presented to the Safety Committee and have been reviewed with team to assure the Fire Drills are completed monthly. |
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
The facility failed to limit the information released to an employer to whether or not the client is in treatment as stated in PA Code 255.5.
Client records were reviewed on March 8, 2019. Client record #5 contained a signed release of information that exceeded what is permissible by 255.5. Letters were sent to the employer on August 9 and October 12, 2018 which exceeded what is permissible by 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager reviewed with Clinical Treatment Team 709.28 Confidentiality and Confidentiality Guidelines for Information Sharing in Accordance with Pa. Code 255.5. (6) Recovery Environment permitted response and NOT permitted was reviewed. Clinical Team will follow code 255.5 when releasing information with an understanding what is permissible by 255.5. This was reviewed and implemented on March 19, 2019. |