INITIAL COMMENTS
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The inspection was conducted on September 16-19, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service and Children's Aid Society of Venango County, 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 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on an observation and a physical plant inspection, the facility failed to provide an unobstructed exit from the front entrance.
The findings include:
A physical plant inspection was conducted on September 16, 2013. A double key deadbolt is located on the two front entrance doors to the building. This exit is not unobstructed and operable at all times.
The finding was reviewed with the facility director and was not disputed.
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Plan of Correction
On Friday September 20, 2013 the D/A Program Director contacted the Community Department Director of Franklin Pa. The Community Department Director is the person who oversee's the physical plant at the Professional Building at 150 Prospect Ave, Franklin PA. She was informed of the licencing citation regarding the two dead bolt locks on the front entrance doors. The Community Department Director indicated she would notify the Fire Chief for the City of Franklin. She will inform him of the necessary changes to a push bar or thumb locks for the two entrance doors.
On October 2, 2013 the D/A Program Director received an email indicating the Fire Chief was in training then off of work for personal reasons. The Community Department Director indicated she would contact him the week of October 7, 2013 to look into the changes.
Completion Date 11/15/2013
The D/A Program Director will notify Licensing of completion date with Pictures to verify. |
709.28(c) 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:
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client prior to the disclosure of information in one of four client records.
The findings include:
Four client records were reviewed on September 16-17, 2013. Four client records were required to include an informed and voluntary consent from the client prior to the disclosure of information.
Record #1 - The client was admitted on April 24, 2013. The facility sent a letter to an agency/medical records department on August 5, 2013, but failed to document a consent to release information form to disclose information to this agency.
The findings were reviewed with the facility director and were not disputed.
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Plan of Correction
A meeting was held with the counselor of the cited chart reviewing the citation. A Mandory staff meeting is being held on October 17, 2013. Both the D/A Program Director and Clincal Supervisor will review this finding with the clinical staff. Each counselor are to monitior their individual charts for proper releases prior to sending out any letters to other agencies. The peer to peer chart checks will continue to occur and they will be signed off that the proper releases are in the charts. The Clinical Supervisor will randomly pull charts of each counselor to verify chart checks are being completed.
Completion Date: October 17, 2013 |