INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 15, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Centers 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection the facility failed to store all trash, garbage, and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on December 18, 2014. During the inspection of the adult dining room and kitchen four garbage cans were observed without lids. The lids were located outside of the kitchen on the loading dock.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Lids are available in the kitchen and have been added to the closing and opening checklist for the kitchen and enforced by the Kitchen supervisor. All staff were made aware of this requirement.
Completed and enforced by the Supervisor of the Kitchen on 12/19/14
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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. 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 obtain informed and voluntary consents in one of nine records reviewed.
The findings include:
Nine client records were reviewed on December 15, 2014. All were reviewed for informed and voluntary consent forms. The facility failed to document informed and voluntary consents in one client records, specifically record, #3.
Client #3 - Consent to release dated December 5, 2014 for the client's significant other failed to have staff's signature and date on the consent to release form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction:
It is policy to have the patient and staff member sign all releases upon admission. This procedure was reviewed with all intake and admissions staff. In order to audit this process a report was developed by our IMS dept. on 1/9/15.
The supervisor of the intake admission department is responsible for implementation and compliance.
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