INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 28, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Conewago Place 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection on July 28, 2022, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling group room Serenity Hall as there was no coverings over the window next to the door leading to the hallway.
These findings were reviewed with facility staff during the inspection process.
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Plan of Correction
On 8/1/2022 Facility staff covered the uncovered window next to the Serenity Hall Door. During the 8/1/2022 Clinical Staff Meeting, Clinical staff were informed that windows in counseling area must covered during sessions. Program Monitors were instructed on 8/2/2022 to report any missing window coverings in counseling session rooms to the Maintenance Supervisor, Assistant Director and/or Facility Director. The Facility Director and/ or Assistant Facility Director are responsible to ensure the presence of window coverings to maintain privacy during counseling sessions. Observation of the coverings shall occur during the weekly safety and sanitation inspections completed by the Facility Director and/or Assistant Facility Director. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on July 28, 2022, the facility failed to ensure that all client bathrooms were supplied with paper towels or a mechanical dryer. Each client bathroom was provided with a towel to wash and dry hands.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will be requesting an exception for this regulations due to the facility providing each client with cloth towels for hand drying upon admission. In the event the exception is not granted, The Facility Director is responsible to ensure the Facility Maintenance Supervisor will install paper towel dispensers in each client bathroom within 4 weeks of the exception decision. A supply of paper towels will be kept on hand in order to replenish the dispensers as needed. |
709.28 (c) (5) 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 must be in writing and include, but not be limited to:
(5) Dated signature of witness.
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Observations
Based on the review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included a dated signature of a witness in one record reviewed.
Client #7 was admitted on May 11, 2022 and was discharged on July 1, 2022. There were four informed and voluntary consent forms to external providers signed by the client dated June 9, 2022, but the consent forms did not include a witness signature.
The findings were reviewed with facility staff during the inspection process.
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Plan of Correction
On 8/1/2022 the Program Specialist that failed to provide the witness signatures was retrained. The retraining included a walk-through the EM signature function and how to troubleshoot for a manual signature input when the finger print scanner is malfunctioning. During the clinical staff meeting, consents were addressed and the need for a witness signature was reiterated. Facility Director went through the steps of how to input a signature manually if finger print scanner is malfunctioning. On 8/2/2022 during the program monitor meetings, consents were addressed and the need for a witness signature was reiterated. Facility Director went through the steps of how to input a signature manually if finger print scanner is malfunctioning. The Clinical Supervisor will continue to conduct random weekly audits to ensure that all signatures are present. The Facility Director will continue to conduct random audits to ensure that all signatures are present. The Clinical Supervisor will be responsible for ensuring proper signatures are present on documentation under the supervision of the Facility Director. Subsequent client files to this finding will be in full compliance with the standard. |