INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 19, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, DARS, Inc. SIL Program was found to be not 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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
Based on a review of Presubmission materials the facility failed to indicate whether the fire alarm or smoke detector was operative during fire drills on October 29, 2016, June 26, 2017 and September 27, 2017.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Two internal training's will be held for all DARS,Inc. Supervised Independent Living staff o review the requirements of completing the fire drill log correctly. The first training is scheduled for 12/10/2017 and the other one is scheduled for 12/16/2017 ; therefore, all DARS,Inc.Supervised Independent Living staff should be trained by 12/16/2017. Upon completion, a certificate will be filed in the employee's training file. Compliance of this POC will be monitored through periodic record checks by the Youth Care Supervisor, Treatment Director, and the Executive Director. |
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
Seven client records were reviewed on October 19, 2017. The facility failed to document a valid consent to release information form in client records #1-7. While the informaton to be released was compliant with 4 Pa. Code 255.5, and there was no eveidence that any information exceeding 4 Pa. Code 255.5 had been released, the purpose of the consent to release information, to a local government agency, was incorrectly listed as " drug testing procedures " .
Client #1 was admitted on 3/27/17 and was an active client at the time of the licensing inspection. The consent to release information to a government agency was dated 3/29/17.
Client #2 was admitted on 7/5/17 and was an active client at the time of the licensing inspection. The consent to release information to a government agency was dated 7/5/17.
Client #3 was admitted on 6/22/17 and was an active client at the time of the licensing inspection. The consent to release information to a government agency was dated 6/22/17.
Client #4 was admitted on 1/17/17 and was discharged on 5/8/17. The consent to release information to a government agency was dated 1/17/17.
Client #5 was admitted on 11/22/16 and was discharged on 4/27/17. The consent to release information to a government agency was dated 11/22/16.
Client #6 was admitted on 5/10/17 and was discharged on 9/25/17. The consent to release information to a government agency was dated 5/17/17.
Client #7 was admitted on 4/28/17 and was discharged on 7/24/17. The consent to release information to a government agency was dated 4/27/17.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The consent in the confidentiality release was corrected at the time it was identified. Current client files identified in this POC will have new consent for release of information forms reflecting the local police municipality for the purposes of releasing client information permitted by PA Law 255.5, as well as any future client files to meet the standard. A clinical staff meeting will be held on 11/27/2017. At this meeting, the SIL Program Director will review the standard operating procedure for all client consent forms and insure the SIL Clinical team is competent in completing the forms so information can be disseminated properly.Compliance of this plan of correction will be overseen through periodic record checks by the Clinical Supervisor.
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