INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11-12, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Independent Family 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 (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 observation and a physical plant inspection, the facility failed to provide an unobstructed exit from the front entrance.
The findings include:
A physical plant inspection was conducted on December 11, 2012. A double key deadbolt is located on the two front entrance doors to the facility. Therefore, this exit is not unobstructed and operable at all times.
The findings were reviewed with the CEO and the project director and were not disputed.
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Plan of Correction
The facility director instructed the IFS office manager to contact Spory's Locksmith to schedule an appointment to have the appropriate thumb latch locking mechanisms installed on the two front entrance doors on 12/12/12. Spory's Locksmith installed the appropriate locking mechanisms on the two front entrance doors on 12/12/12. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel/training records, the facility failed to document the instruction of staff in the use of the fire extinguisher in three of three personnel training records.
The findings include:
Three personnel records were reviewed on December 12, 2012. All three personnel records were required to document fire extinguisher training. The facility failed to document the completion of fire extinguisher training in personnel records # 1, 2 and 3.
Employee # 1 was hired into the drug and alcohol activity on July 1, 2012. The training was due at the time of employment. The training was not documented as of the December 12, 2012.
Employee # 2 was hired into the drug and alcohol activity on July 1, 2012. The training was due at the time of employment. The training was not documented as of the December 12, 2012.
Employee # 3 was hired into the drug and alcohol activity on October 11, 2012. The training was due at the time of employment. The training was not documented as of the December 12, 2012.
The findings were reviewed with the CEO and the project director and were not disputed.
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Plan of Correction
To document completion of fire extinguisher training in personnel records, the new employee checklist has been modified to indicate the date on which the employee completed the training and an initial/date line for the employee to verify that training had been completed. Fire extinguisher training will be completed within seven days of hire, as per regulation. Employee #1, Employee #2, and Employee #3 will complete fire extinguisher training on 2/7/13. Completion of the training will be documented according to policy. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel/training records, the facility failed to document that staff are trained for emergencies in three of three personnel/training records.
The findings include:
Three personnel records were reviewed on December 12, 2012. All three personnel records were required to include documentation of emergency training. The facility failed to document the completion of emergency training in personnel records # 1, 2 and 3.
Employee # 1 was hired into the drug and alcohol activity on July 1, 2012. The training was due upon employment. The training was not documented as of the December 12, 2012.
Employee # 2 was hired into the drug and alcohol activity on July 1, 2012. The training was due upon employment. The training was not documented as of the December 12, 2012.
Employee # 3 was hired into the drug and alcohol activity on October 11, 2012. The training was due upon employment. The training was not documented as of the December 12, 2012.
The findings were reviewed with the CEO and the project director and were not disputed.
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Plan of Correction
To document completion of emergency training in personnel records, the new employee checklist has been modified to indicate the date on which the employee completed the training and an initial/date line for the employee to verify that the training had been completed. Emergency training will be completed within seven days of hire, as per regulation. Employee #1, Employee #2, and Employee #3 will complete emergency training on 2/7/13. Completion of the training will be documented according to policy. |
709.26(b)(2) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(2) The dissemination of employment information to project staff.
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Observations
Based on a review of the facility policy manual, and a conversation with the CEO and the project director on December 11-12, 2012, the facility failed to provide a policy for the dissemination of employment information to project staff.
The findings include:
The facility policy manual was reviewed on December 11, 2012, and it did not include a policy for the dissemination of employment information to the staff.
The findings were reviewed with the CEO and the project director and were not disputed.
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Plan of Correction
Regarding regulation 709.26 (b)(1-4), the IFS policy and procedure manual has been modified so that subsection (2) explicitly defines how the dissemination of information to project staff will be facilitated. The policy statement in subsection (2) now reads as follows:
(2) The dissemination of employment information to project staff will be facilitated through the use of company email, typed memos, and/or staff meetings.
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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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of the client records, the facility failed to document consent to release information forms which listed the specific information to be disclosed in three of three client records.
The findings include:
Three client records were reviewed on December 12, 2012. The consent to release information forms in client records # 1, 2 and 3 did not include the specific information that was to be disclosed.
Client # 1 was admitted on December 6, 2012. A consent to release information form was signed on December 6, 2012 for a release of information to the Single County Authority. The facility failed to list the specific information that was to be disclosed on the consent to release information form.
Client # 2 was admitted on November 12, 2012. A consent to release information form was signed on November 12, 2012 for a release of information to the Single County Authority. The facility failed to list the specific information that was to be disclosed on the consent to release information form.
Client # 3 was admitted on October 29, 2012. Consent to release information forms were signed on October 29, 2012 for a release of information to the Single County Authority and the probation office. The facility failed to list the specific information that was to be disclosed on the consent to release information form.
The findings were reviewed with the CEO and the project director and were not disputed.
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Plan of Correction
In order to appropriately document the specific information to be disclosed on the consent to release information form, the form was modified on 12/12/12 to reflect the 5 points of information allowable to be released according to applicable regulation. The patient will initial the form next to each point of information to be released, in addition to signing the form to indicate overall consent. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of the client records, the facility failed to document the client was offered copies of written consents to release information in three of three client records.
The findings include:
Three client records were reviewed on December 12, 2012. The consent forms in client records # 1, 2 and 3 did not indicate that the client was offered a copy of the written consent.
Client # 1 was admitted on December 6, 2012. A consent to release information form was signed on December 6, 2012 for a release of information to the Single County Authority. The facility failed to document that the client was offered a copy of the written consent to release information.
Client # 2 was admitted on November 12, 2012. A consent to release information form was signed on November 12, 2012 for a release of information to the Single County Authority. The facility failed to document that the client was offered a copy of the written consent to release information.
Client # 3 was admitted on October 29, 2012. Consents to release information forms were signed on October 29, 2012 for a release of information to the Single County Authority and the probation office. The facility failed to document that the client was offered a copy of the written consent to release information.
The findings were reviewed with the CEO and the project director and were not disputed.
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Plan of Correction
The consent to release information form was modified on 12/12/12 to indicate whether the patient did or did not request a copy of the form through the use of a check box. |