INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Women ' s Institute of Family Health 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection on July 11, 2022, the facility failed to keep the grounds of the facility clean, safe, and sanitary at all times as the rear yard contained a low hanging wire, two uncovered trashcans on their sides, and an open paint container.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will have the trash cans covered, the hanging telephone wire removed and the open paint container discarded. The receptionist will check the rear exit upon opening the office daily to inspect the conditions of the rear exterior and she will remove any objects obstructing the rear and she will make sure the trash cans are covered and she will notify the phone company in the event of hanging wires. The receptionist will keep a daily log and enter the conditions of the rear exit and will document any corrective actions taken with her signature. The Executive Director will review the log on a weekly basis to assure that there are no reoccurrence of this deficiency. To be accomplished by 8/16/22 |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection on July 11, 2022, the facility failed to ensure that exits from the nonresidential facility are unobstructed as the gate to exit the facility property through the rear emergency exit was locked.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director will remove locks that obstruct exit from the rear emergency exit of the property by 7/28/2022 To avoid reoccurrence the Receptionist will inspect the rear exit daily upon opening the office. She will unlock and remove the locks each day. In the event the locks are changed by another person preventing her from removing with a key, a locksmith will be called to remove the locks. The receptionist will maintain a daily log of the conditions of the rear exit and will enter any corrective action taken. The Executive Director will review the log on a weekly basis |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the specific information to be disclosed in two records reviewed.
Client #4 was admitted on October 19, 2021 and was discharged December 28, 2021. The record contained a consent to release information form to a family member signed by the client on October 19, 2021 that was missing the specific information to be disclosed.
Client #7 was admitted on October 26, 2021 and was active at the time of the inspection. The record contained a consent to release information form to the funding source signed by the client on October 26, 2021 that was missing the specific information to be disclosed.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director shall insure that all client records contain specific information to be disclosed on the consent to release form. This will be accomplished by reviewing each form with the client at the time of their intake to verify that there is no missing specific information to be disclosed on the form. To be accomplished by 8/15/2022. This will be corrected by mandating in office policy and job descriptions that the counselor not begin the treatment process without verifying that the consent to release information form is completed. The Executive Director will revise job descriptions and office policies and require understanding and acknowledgment through signature of clinical staff. The form was updated to include all applicable specific information to be disclosed for client #7 on 7/14/2022 |
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 a review of seven client records, the facility failed to ensure that consent to release information forms included the dated signature of a witness in one record reviewed.
Client #3 was admitted on October 12, 2021 and was discharged on January 3, 2022. The record contained a consent to release information forms to a parole officer and the funding source signed by the client on October 12, 2021, that were missing the dated signature of the witness.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director shall ensure that all client consent to release information forms include the dated signature of a witness in each client record. This will be accomplished by reviewing the form with each client at the time of intake. To be accomplished by 8/15/22
The counselor will be mandated not to begin treatment without verifying that there is a witness signature on the consent to release form. The counselor must require that the client sign the form in his/her presence and the counselor will be required to witness the signature. The Executive Director will revise office policies and job descriptions to include this requirement and clinical staff will sign acknowledgment and understanding of this policy. |