INITIAL COMMENTS
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This report is a result of an on-site, licensure renewal inspection conducted on July 22, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service & Children's Aid Society 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on July 22, 2016, the facility failed to ventilate the front restroom by an exhaust fan or window.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On Monday, August 1st the Drug & Alcohol Program will discuss with the Executive Director of Family Service & Children's Aid Society the violation of Policy 705.24 due to the exhaust fan not working in the front bathroom of the Titusville office. The Executive Director or Program Director will contact persons responsible for maintenance of our Titusville office to resolve the issue of the non working exhaust fan in the bathroom. Any and all repairs will be completed no later than Friday September 2,2016. |
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 a review of the client records on July 22, 2016, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in two of ten client records. Information of disclosure to another government agency was documented in a "Report of Contact" progress note for client records #9 and #10. Neither client record #9 and #10, had a release of information signed by the client allowing for the disclosure of that information. The findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A meeting with the individual counselor by the Program Director occurred on Wednesday,July 28th discussing the citation and reviewing the errors of not completing a release of information and disseminating information without authorization. The counselor will obtain a signed release of information by the client at the next scheduled appointment. Also, a clinical staff meeting conducted by the Clinical Supervisor was held on Monday, July 25th and she reviewed and discussed the findings of the Licensure visit to all clinical staff members and discussed the proper monitoring of the release of information form. Routine chart checks will continue to be completed by the clinical staff, Clinical supervisor and Program Director. Client charts will randomly be pulled of all clinical staff to verify chart checks are being competed and to monitor the accuracy of all paperwork,including the release of information. |