INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 23, 2017 through January 24, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, conducted January 24th at approximately 11:00 a.m., it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room as evidenced by:
1.A group session was being held in the first floor group room (by the double doors) of the carriage house and could be overheard in the hallway.
2.An individual session was being held in Room 300 of the mansion and could be overheard in the hallway.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will purchase white noise machines for identified areas. These machines will be turned on during groups. Machines were purchased and arrived on 2-9-17. Machines will be installed and use will begin on 2-14-17. Facility Director and Clinical Supervisors will monitor compliance through regular walkthroughs of affected areas. |