INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 24 - 25, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Counseling and Adoption Services, 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) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill log and an interview with the project director, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
A review of the fire drill log was completed. The fire drills conducted from March 2014 - January 2015 were reviewed. The fire drills documented only the back door exit was utilized. The facility did not document any alternate exits used during fire drills.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Beginning with the March 2015 agency fire drill, the Facility Director will ensure that at least twice a year an alternative exit is required to be used during the fire drill evacuation procedure. The agency Admin Team, during its bi-annual facility safety review process, will monitor the agency fire drill logs to ensure that fire drills have occurred monthly and that at least twice a year alternative exits are required during fire drills. |
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. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent from the client prior to disclosure of information in three of ten client records.
The findings included:
Ten client records were reviewed on February 24 - 25, 2015. Ten client records were required to document an informed and voluntary consent from the client prior to the disclosure of information.
Client #8 was admitted to treatment on November 5, 2014. A release of information for the probation department was signed by the client on November 5, 2014, but did not include a witness signature, or the specific information to be disclosed.
Client #9 was admitted to treatment on November 20, 2014. A release of information for a funding source was not obtained prior to disclosure.
Client #10 was admitted to treatment on December 15, 2014. A release of information for a funding source was signed on December 15, 2014, but did not include the specific information to be disclosed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Program Director met with the worker who was responsible for all of the indiscrepancies reported by the site reviewer. This worker, and the other counselor on staff were notified the identified problem areas and the following procedures were put into place OR reviewed with the workers....
1. ALL clients MUST sign a Release of Information for disclosures to a funding source at the initial session.
2. All releases must contain information re: the specific information that will be disclosed to the agency/entity for whom the release is being signed.
3. Workers MUST sign the Release of Information at the SAME TIME as the client is signing it.
4. The Program Director will review Releases of Information during chart reviews to ensure that these procedures are being properly followed. |