INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 10, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Central Outreach Resource and Referral Center 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of facility records, the facility failed to maintain a written fire drill record including the exit route used and problems encountered.
No fire drill records from January, 2023 through September, 2023 contained what exit was used during the drill, as well as if any problems were encountered during the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 705.28 in the conduct fire drills during normal staffing working hours
The program Director will ensure that the fire Drills will have in its log book which exit door was use and a listing of if there was any encounters when the Fire Drill is underway hours.
To ensure that this does not recur, the Program Director will review the fire drill log book and document if there was any encounters and which exit Door was used.to meeting DDAP requirement as state in DDAP regulation
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of facility records, the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures for the year 2023. The facility was unable to provide any signed manual delineating project policies and procedures from 2023 or any previous year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
Central Outreach Center in response to Deficiencies 705.28 found doing a site Licensure renewal inspection conducted on 10/10/2023. Policy and Procedures must include a yearly review of the Policy and Procedures.the program director to prepare, annually update and sign a written manual
The Program Director will ensure that the Policy and Procedures has been reviewed and signed and dated yearly by the program director
To ensure that this does not recur, the Program Director will have all Board Office be made aware of the responsibility to reviewing of the policies and Procedure and to signed off that they have received the necessary training and information the is needed to be made a wear of this responsibility.
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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 client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven records.
Client #1 was admitted for intake, evaluation, and referral on March 27, 2023. Case notes contained in the client ' s record indicate that on March 28, 2023 and March 31, 2023 the facility corresponded with client #1 ' s emergency contact about the status of the client ' s treatment. Client #1 ' s record did not contain an informed and voluntary consent allowing the facility to correspond with the emergency contact about the client ' s treatment.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of correction
Central Outreach Resource and Referral Center has created the following plan of Correction in response to deficiencies 709.28 confidentiality the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record
The program Director will ensure that confidentiality the project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. the Director shells develop a signature sheet in the client files and it will be double check and sign off that all consent is sign and dated and every folder will be check by another Case Manager as a peer review
To ensure that this does not recur, the program Director will review the client folder to check that all consent forms are signed and dated and peer review check list in the back of every folder so a Case Manager can do a client file check list/ or Peer review. therefore, meeting as stated in the DDAP licensure regulations
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