INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 5, 2009 through January 7, 2009, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pennsylvania Counseling Services Renaissance, 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 and a plan of correction is due on February 7, 2009.
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Plan of Correction
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705.28 (d) (8) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(8) Prohibit the use of elevators during a fire drill or a fire.
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Observations
Based on a physical plant inspection of the facility, the facility failed to indicate the use of the elevator used by client, staff, and other visitors of the facility is prohibited during a fire drill or a fire.Findings:A physical plant inspection of the facility occurred on January 7, 2009. It was observed by the licensing specialists that there was no sign, either inside or outside of the elevator used by client, staff, and other visitors of the facility, indicating use of the elevator is prohibited during a fire drill or a fire.
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Plan of Correction
A sign has been posted outside of the elevator indicating that use of the elevator is prohibited during a fire drill or a fire. |
709.28(a)(1) 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 shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to document a written procedure that shall comply with 4 Pa. Code 255.5.Findings:The facility's policy and procedure manual was reviewed on January 5, 2009 and January 6, 2009. The facility's policy regarding confidentiality of client identity and records included language allowing the facility to disclose information to the parent or guardian of a minor without the minor's consent.
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Plan of Correction
The Quality Improvement Department will revise the confidentiality policy to comply with all federal and state confidentiality laws. |
709.93(a)(9) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan, where required.Findings:Sixteen client records were reviewed on January 7, 2009. Aftercare plans were required in six client records. The facility failed to document an individualized aftercare plan, including an identification of the client's personal goals and objectives, in six of six client records, # 5, 7, 8, 13, 15, and 16.
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Plan of Correction
The Quality Improvement Department has revised the Aftercare Plan to include prompts to remind therapists to create individualized goals. The QI Department will also be re-educating clinical staff via staff meeting to develop individualized aftercare plans with personal/measurable goals and objectives. QI will then monitor on-going compliance through random chart reviews and re-educate staff as necessary. |