INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 25, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Daystar Center for Spiritual Recovery was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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
A physical plant inspection was conducted on January 25, 2017. Base on this inspection, the facility failed to ensure the exits from the facility were unobstructed as at the time of the inspection, the rear exit door on the back side of the building from the basement was damaged and hard to open.
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Plan of Correction
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.
(a) Daystar has corrected the fire safety issue of failure to ensure the exit in the basement complies with 705.10 (a) (1) (i). A Repair was completed on 1/25/2017 while inspector was still onsite. The door was repaired to provide ease of exit. The exit doors thought the entire building have been added to the monthly inspection of the facility, for fire safety. Daystar maintenance will ensure compliance of fire safety and the Executive Director will ensure overall compliance.
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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
A review of ten client records was conducted on January 25, 2017. Based on this review, the facility failed to obtain an informed and voluntary consent form from the client with what specific information was being disclosed. Client #1 was admitted 12/13/16 and was still receiving services. The informed and voluntary consent form for Drug Court had other information will be released checked but it did not state what the other information would be. Client #2 was admitted 12/16/16 and was still receiving services. The consent for release form from the referral source had other information will be released checked but did not state what the other information would be. Client #3 was admitted 12/1/16 and was still receiving services. The consent for release form from the funding source had other information will be released checked but did not state what the other information would be. Client #4 was admitted 11/7/16 and was still receiving services. The consent for release form from the funding source had other information will be released checked but did not state what the other information would be. Client #5 was admitted 11/4/16 and was still receiving services. The consent for release form from the funding source had other information will be released checked but did not state what the other information would be. Client #6 was admitted 8/22/16 and discharged on 11/10/16. The consent for release form from the funding source had other information will be released checked but did not state what the other information would be. Client #7 was admitted 9/2/16 and discharged 12/1/16. The consent for release form from the funding source had other information will be released checked but did not state what the other information would be. Client #8 was admitted 7/7/16 and discharged 10/17/16. The consent for release form from the funding source had other information will be released checked but did not state what the other information would be. Client #9 was admitted 4/25/13 and discharged 7/19/16. The consent for release form from the funding source had other information will be released checked but did not state what the other information would be. Client #10 was admitted 10/11/16 and discharged 12/14/16. The consent for release form from the funding source had other information will be released checked but did not state what the other information would be. These findings were reviewed with facility staff.
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Plan of Correction
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.
(a) Daystar made the necessary changes to the consent form while the inspector was still onsite 1/25/2017. The prior consent had a check box for other information. The check box was inappropriately checked and "other information" was blank. In order to comply with 709.28(c)(2), the check box has been removed entirely from the consent for. Going forward, a new release of information has replaced the old consent form. If further information is to be released, it will be written into the consent by hand giving specific details of the information to be disclosed on that consent. The consents in Current client charts have been destroyed and new consents have been signed.
The Clinical Supervisor will ensure compliance to all confidentiality regulations and the Executive Director will ensure overall compliance.
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