INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder 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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705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant inspection conducted on August 9, 2017 at approximately 10:30 a.m., the facility failed to ensure that exits from the residential facility were unobstructed. The second exit from the trailer building was located in an office. The door to this office could be locked from inside the office, and thus could have obstructed exit from the trailer.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The doorknob of the second exit was changed and a non-locking knob was installed on August 9, 2017 by the maintenance staff.
Maintenance staff will ensure that no other door locks prohibit a means of egress during the month safety inspections. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection conducted on August 9, 2017 at approximately 10:30 a.m., the facility failed to clearly indicate exits by the use of signs. The second exit from the trailer building was located in an office, but there was not an exit sign above the office door to indicate the exit.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
An exit sign was installed above the second exit door to indicate an exit by maintenance staff on August 9, 2017.
Maintenance staff will ensure all exits are clearly marked by exit signs during the monthly safety inspection. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of facility records conducted during the onsite inspection, the facility failed to include all of the required information on its consent to release information forms in 1 of 8 records reviewed.
Client #1 was admitted for treatment on 06/29/2017, and was an active client at the time of the onsite inspection. The following signed informed consent to release information forms did not have an expiration date.
Consent to release to Neurologist dated 08/09/2017.
Consent to release to primary care physician dated 08/09/2017.
Consent to release to County Clerk of Courts dated 07/21/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
A meeting was held with all clinical staff and the proper way to complete a Consent to Release Information form was reviewed.
The Clinical Director will ensure continual compliance during monthly client record audits. |