INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 9, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Services of Warren County, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that there were no heaters located within the facility that were not permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on March 9, 2016 at approximately 10:00 AM.
A portable space heater that was not permanently mounted or installed was observed in the receptionist area in room 226 - B.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director has removed all space heaters effective 3/9/16 and the Facility Director and or Program Director will inform staff that space heaters are not to be used in the office space at anytime. This will occur at the next staff meeting on 3/29/16. The Facility Director and or Program Director will complete quarterly walk through to make sure the policy prohibiting space heaters is complied with. |
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 an informed and voluntary consent form in two of eight client records reviewed.
The findings include:
Eight client records requiring informed and voluntary consent to release forms were reviewed on March 9, 2016. The facility failed to document the purpose of disclosure on the informed and voluntary consent to release forms in client records, #2 and 8.
Client #2 -The facility failed to document the purpose of disclosure on an informed and voluntary consent to release form to a treatment facility dated September 16, 2015.
Client #8 -The facility failed to document on two informed and voluntary consent to release forms the purpose of disclosure. One consent to release form was dated October 8, 2015 to a treatment provider and the other was dated July 14, 2015 to a government agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and or Program Director will complete a training at the next staff meeting on 3/29/16 reviewing the requirement to have all appropriate fields marked on a release of information, specifically the purpose of disclosure. The Facility Director will follow up with each staff in supervision and at least quarterly randomly audit charts. |