INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 27-28, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Glenbeigh Center of Erie 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of administration information, the facility failed to collect feedback on completed trainings.
The training year beginning July 1, 2022 through June 20, 2023 was reviewed and feedback was not collected for any training.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will train staff on the need to provide feedback sheets on all completed trainings. The already developed feedback sheet will be attached to all future training CEU's. Program director will be in charge of collecting and compiling all CEU's accumulated by current staff during the yearly training period. Any CEU's submitted by staff without feedback sheets will be rejected and returned to staff with the instruction to attach feedback sheets to the CEU certificates. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18 inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, the facility failed to maintain steps and railing from back exit. The steps and railing were removed for construction and were not reattached.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director contacted the facility landlord and steps and a railing will be reattached to the previous space that they were in before construction. Any future construction will be monitored by the program director in order to maintain compliance with regulations. |
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
Based on a review of fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill.
Reviewed fire drills from July 2022 to July 2023 and the fire alarm was not set off during drills conducted on July 11, 2022, November 14, 2022, December 21, 2022, January 30, 2023, February 28, 2023, March 13, 2023, April 11, 2023, May 22, 2023, June 6, 2023, and July 7, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will make sure the fire alarm is set off during all future fire drills. This will be documented in the fire drill and safety log. Program Director will monitor the fire drill and safety logs monthly and if a fire drill takes place without setting off the fire alarm, the fire drill will be reinitiated by the program director. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to provide a purpose for disclosure on a release of information form in one of seven client records.
Client #2 was admitted on May 15, 2023 and was still an active client. A release of information form to a primary care physician was signed by the client on September 13, 2023, and did not indicate the purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director will train all staff on the necessity of completely filling out all release of information documents going forward. This will be monitored by the Program Director and Office Coordinator upon the signing of releases. Any incomplete release of information documents evident upon monitoring will be filled out completely and resigned by the client. All current client charts will be reviewed including client #2 who was in the citation by the program director to ensure all current client charts are in compliance. |