INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 25-26, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Summit Academy 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 December 17, 2007.
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Plan of Correction
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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant tour on 10-25-07 at 11:00 am, the facility failed to provide an unobstructed exit from the third floor. A chair was blocking the door making the exit difficult to access.
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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. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the personnel records on 10-25-07, the facility failed to provide training in the use of fire extinguishers within seven days of the employee's date of hire. This was found to be lacking for one of two applicable employees. Refer to personnel record #4.
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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. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the personnel records on 10-25-07, the facility failed to provide emergency preparedness training within seven days of the employee's date of hire. This occurred in one of two applicable personnel records reviewed. Refer to personnel record
#4.
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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) 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:
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Observations
1.) Based on client record reviews on 10-26-07, the facility failed to remove Parent/Guardian signature lines from consent to release information forms noted in client records # 4 and 5. In accordance with the federal regulation at 42 CFR Part 2, Subpart B, Subsection 2.14(b) in states where the minor has a right to seek treatment no his own without parental consent, (see 71 P. S. Subsection 1690.112) only the minor has the right to consent to the release of information.
2.) Based on client record reviews and conversations with the director on 10-26-07, the facility failed to provide a Qualified Service Organization Agreement (QSOA) or a signed release form prior to the disclosure of client information to the dental program who provides dental services for all clients.
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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. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on clinical record reviews on 10-26-07, the facility failed to provide family medical histories for four of five applicable client records reviewed. Refer to client records # 1, 2, 4 and 6.
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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. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on client records reviewed on 10-26-07, the facility failed to include all required areas in the psychosocial evaluations in three of five client records. Components which are consistently missing include coping mechanisms, negative factors affecting treatment, client assets and strengths, and the clinicians impressions. Refer to client records # 1, 3 and 5.
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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. |
709.53(a)(5) LICENSURE Progress Notes
709.53. 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:
(5) Progress notes.
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Observations
Based on client records reviewed on 10-26-07, the facility failed to provide the clinical assessment of the session in three of five client records. Refer to client records # 2, 3 and 4.
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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. |