INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Renew Family Services, LLC 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's March 2022 through March 2023 fire drill logs, the facility failed to include the time of the fire drill conducted on January 18, 2023 on their fire drill log.
This is a repeat citation from the March 29, 2022 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 5/1/20223 a new Fire Drill Form was created to include all the necessary elements of the standard including time of drill.
The Executive Director is in charge of compliance and training of this form. The office administrator will audit the fire drill process and forms each month to ensure compliance. |
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 facility's March 2022 through March 2023 fire drill logs, the facility failed to prepare alternate exit routes for each fire drill conducted. Every fire drill conducted during the reviewed period utilized the front door as the exit route.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 5/1/20223 a new Fire Drill Form was created to include all the necessary elements of the standard including time of drill, exits/routes used, blocked etc. This form will be used for all drills going forward.
The Executive Director is in charge of compliance and training of this form. The office administrator will audit the fire drill process and forms each month to ensure compliance. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom disclosure is made on a consent to release information form in one of nine client records reviewed.
Client #4 was admitted on October 18, 2022 and was discharged on February 9, 2023. A release of information form was signed and dated by the client on October 17, 2022; however, the consent form did not include the specific name of the person, agency, or organization to whom the disclosure was to be made.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective 5/1/23 The Office Administrator will audit all all consents prior to being uploaded into the EMR. They will specifically ensure that the releases include: the name of the person, agency, or organization to whom disclosure is made as well as the signatures of the client and staff.
The Executive Director is in charge of implementation and compliance and will monitor the audits through supervision of the office administrator.
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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 record.
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Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent form was offered to the client in one of nine client records reviewed.
Client #8 was admitted to partial hospitalization on October 7, 2022 and was discharged on December 6, 2022. There was a release of information form to an emergency contact signed and dated by the client on November 1, 2022; however, there was no documentation that indicated a copy of the consent form was offered to the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective 5/1/2023 all staff were trained to ensure that they properly document release of information in the EMR as well as indicate that a copy of the consent form that the client signed are offered to them. This training will also be added to new employee orientation.
The Executive director is in charge of implementation and compliance and it will be monitored through chart reviews. |