INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 16, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Chartiers Community Mental Health and Retardation Center, Inc. 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
The facility failed to document a fire drill record for January through December 2017 that included the exit route use, 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 based on a review of fire drill records during the annual licensing inspection conducted on January 16, 2018.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
The previously approved Fire Drill form was revised to be in full compliance and include 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. The form has already been implemented and the Facility Director who began using such effective January 11, 2018.
The documentation on the fire drill form, which is in full compliance and includes 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 shall be completed in full by the Facility Director effective January 16, 2018 and ongoing thereafter.
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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
The facility failed to document an informed and voluntary consent from the client prior to the disclosure of information contained in the client record in two of seven records reviewed during the annual licensing inspection conducted on January 16, 2018.
Client # 4 was admitted on May 25, 2017 and discharged on June 28, 2017. The facility disclosed the client's name, level of care, progress and prognosis to the court system by fax on June 28, 2017.
Client # 7 was admitted on July 7, 2017 and discharged on January 27, 2018. The facility disclosed the name and diagnosis of the client to the funding entity to request authorization for counseling services on July 7, 2017.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The individual who disclosed the information is no longer an employee and no action/ training can be completed. Additional training for existing staff will, however, be conducted by the Facility Director as follows:
By January 31, 2018, the Facility Director shall conduct training, utilizing the regulations and discussion, for existing staff regarding regulations related to disclosure to ensure that there is complete documentation of informed and voluntary consents prior to any disclosure.
Effective January 16, 2018 and ongoing thereafter, the Facility Director shall ensure that there is complete documentation of informed and voluntary consents prior to any disclosures by reviewing all disclosures prior to occurrence and verifying adherence to relevant regulations regarding disclosure.
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