INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 29, 2022, 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the March 2021 through February 2022 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation that a fire drill was conducted during the month of January 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
An unannounced fire drill will be conducted monthly and documented by administrative staff. Clinical Director will make sure that this is completed every month. |
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 March 2021 through February 2022 fire drill logs, the facility failed to identify, on the drill logs, the amount of time it took for evacuation during all fire drills conducted from March 2021 through February 2022.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Unannounced fire drills will be documented with the amount of time it took to conduct the drill monthly by administrative staff. Clinical Director will oversee that the documentation includes the amount of time evacuation took to conduct on the fire drill form. |
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 client records, the facility failed to document the dated signature of a witness on release of information forms in one of seven client records reviewed.
Client #1 was admitted on January 31, 2022 and was active at the time of inspection. There were release of information forms to an emergency contact, a funding source and a laboratory signed by the client on January 28, 2022. However, the dated signature of a witness was documented on January 30, 2022 on all three release of information forms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All consents will be witnessed and signed the same date as clients' signatures by therapist and/or administrative staff. Clinical Director will oversee that all therapists are signing the consents the same day as the client signs them. If the client has been discharged, administrative staff will contact old clients to correct old consents. All consents will be dated correctly and Clinical Director will review charts for these corrections. Client #1 future consents will be signed as the same date to witness signatures. Client #1 will have new consents that have the same date for both signatures by April 19th. |