INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on September 20, 2006.
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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
The organization failed to maintain and install one operable automatic smoke detector on the second floor.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c)(2) 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. The consent shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
In client record #1, the information to be released to the Office of Vocational Rehabilitation was in excess of 4 Pa. Code subsection 255.5(b) restrictions, which limits the information to be released to government entities.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.28(c)(4) 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. The consent shall be in writing and include, but not be limited to:
(4) Dated signature of client or guardian.
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Observations
In client record # 1, the organization failed to obtain dated signatures on authorization to release forms.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
In client record # 1, the organization failed to demonstrate efforts toward informing clients of their rights.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
In client record # 1, the organization failed to document client orientation in regard to admission criteria , treatment completion and discharge criteria.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
In client record # 1 the organization failed to document client orientation in regard to services to b e provided.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
In client record # 1 the organization failed to include time frames with the client's future goals.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |