INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 4, 2020 through February 5, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, UHS Recovery Foundation, 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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705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
The facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times as the men's bathroom, located in the hallway, had a cracked wall behind the toilet, as well as missing tiles along the base.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility's Director of Maintenance met with the building's owner on 02/06/2020 to inspect necessary repairs to the men's bathroom. It was agreed that all repairs will be made with 30 days. This was later updated to be completed by 2/28/2020. The Director of Maintenance will complete at least monthly, compliance check. The results of which will be reported in monthly Safety Committee meeting. In addition, all staff has been re-educated by the Chief Clinical Officer, to bring any safety and, or maintenance concerns to a supervisor's and the Director of Maintenance's immediate attention. |
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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to document the specific information to be released on a consent to release information form to a government agency/funding source in 8 of 14 applicable client records reviewed.
Client # 1 was admitted to the outpatient level of care on June 18, 2019 and was discharged on October 31, 2019.
Client # 5 was admitted to the outpatient level of care on April 30, 2019 and was discharged on July 22, 2019.
Client # 7 was admitted to the outpatient level of care on August 29, 2019 and was active at the time of the inspection.
Client # 8 was admitted to the outpatient level of care on October 30, 2019 and was active at the time of the inspection.
Client # 9 was admitted to the outpatient level of care on September 10, 2019 and was active at the time of the inspection.
Client # 12 was admitted to the outpatient level of care on July 23, 2019 and was active at the time of the inspection.
Client # 13 was admitted to the outpatient level of care on August 27, 2019 and was active at the time of the inspection.
Client # 14 was admitted to the outpatient level of care on May 7, 2019 and was active at the time of the inspection.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
All staff members were educated, by the Chief Clinical Officer, to manually input the specified purpose of the release, such as to be in compliance with the regulation. Compliance will be monitored through ongoing monthly chart audits conducted by the Clinical Manager, and will be reported to the Performance Improvement Committee on a monthly basis. The identified release of information form will be updated, to compliance, for all active clients by 3/13/2020. In addition, the facility leadership provided feedback to the County SCA, with a recommendation to update the specified release of information in alignment with compliance standards for facilities. |