INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 8, 2006 through May 9, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during the inspection and a plan of correction is due on June 12, 2006.
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Plan of Correction
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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
This instruction was not completed within the required time frame for employee #4, #7, #8 and #9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
This training was missing for employee #5 and was completed late for employees #7 and #9.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Neither the fire alarm or the smoke detector was set off for the fire drills conducted.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
A HIPAA consent form signed by all clients includes language that allows for the release of information exceeding the parameters of 4 Pa. Code 255.5.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
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
Whether or not a copy of the consent was offered to the client was not consistently documented in all client records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The composite picture was not an evaluative summary of the collected historical information in three (#1, #2 and #6) of six client records reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Follow up information was not documented according to policy in one (#5) of one client record reviewed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health |