INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 1 - 3 & 6, 2019 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, Arc Manor - Leechburg Satellite 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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709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
The facility failed to provide a procedure addressing the security and release of electronic client records.
Facility procedures were reviewed on May 1, 2019.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The confidentiality policy will be updated by the Executive Director to include information regarding the electronic health record (EHR) and the mechanisms in place to protect confidential information. The Executive Director will seek the Board of Directors' approval on the updated policy at the monthly Board Meeting on 5/20/19. The policy will then be distributed to the staff via email on 5/21/19. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
The facility failed to develop a policy and procedure for the significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence which closes the facility for more than 1 day.
Policy and procedures were reviewed on May 1, 2019.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Executive Director will update the Unusual Incidents Policy to include for the significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence which closes the facility for more than 1 day, and will seek Board approval at the monthly Board Meeting on 5/20/19. The updated policy will then be distributed to staff via email and reviewed in the clinical staff meeting on 5/23/19 by the Clinical Director and with clinical assistants at the Clinical Assistant meeting on 5/28/19 by the Lead Clinical Assistant. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
The facility failed to develop a policy and procedure for a theft, burglary, break-in or similar incident at the facility.
Policy and procedures were reviewed on May 1, 2019.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Executive Director will update the Unusual Incidents Policy to include a theft, burglary, break-in, or similar incident at the facility, and will seek Board approval at the monthly Board Meeting on 5/20/19. The updated policy will then be distributed to staff via email and reviewed in the clinical staff meeting on 5/23/19 by the Clinical Director and with clinical assistants at the Clinical Assistant meeting on 5/28/19 by the Lead Clinical Assistant. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to include the presence of an ambulance in the policy and procedure.
Policy and procedures were reviewed on May 1, 2019.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Executive Director will update the Unusual Incidents Policy to include the presence of an ambulance, and will seek Board approval at the monthly Board Meeting on 5/20/19. The updated policy will then be distributed to staff via email and reviewed in the clinical staff meeting on 5/23/19 by the Clinical Director and with clinical assistants at the Clinical Assistant meeting on 5/28/19 by the Lead Clinical Assistant. |