INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Diocese of Harrisburg, PA, 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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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, a bathroom located in room 14D had an exhaust fan that was inoperable.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 1, 2021 annual licensing inspection.
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Plan of Correction
The program followed program policy by conducting a monthly maintenance checklist. According to the the building inspection conducted August 31, 2022 the exhaust fan was working properly. It became inoperable within the 2 weeks before inspection. There were no residents assigned in the room to report it malfunctioning in the meantime. The POC would be to continue to conduct monthly building inspections and correct inoperable exhaust fans as needed. The citation from last year included having no exhaust fans in some bathrooms versus having inoperable ones. One exhaust fan was inoperable out of 15 exhaust fans. There is no pattern of inoperable exhaust fans only an exception. The agency will continue to correct this issue by following policy. The Program Director will continue to conduct Building Inspections by assigning a staff member each month to complete the inspection and report inoperable facilities to the PD who will then coordinate with the agency Maintenance Department to repair the item. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of the facility's fire drill log for the months of September 2021 through September 2022, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There was only one overnight fire drill documented on December 21, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The overnight staff was unaware the fire drill had to be done after curfew and before the first wake up call. So, the employee conducted a fire drill in April 2022 when clients were sleeping, but it was not done according to the sleeping hours printed on the Program Schedule. All staff were re-trained by the PD and taught the definition of an overnight fire drill at the October 12 staff meeting 2:30pm. Staff are now all aware that an overnight drill does not mean conduct when clients are sleeping, but to conduct during sleeping hours according to the Program Schedule. This POC is complete. |
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
Based on two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the specific information disclosed prior to the release of information.
Client # 1 was admitted on February 10, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated February 10, 2022 to a vocational education agency allowed for the release of whether the client was in treatment or not. Information documented in the client record released information that exceeded what the release allowed to include diagnosis, prognosis, disability, recommendations, and client demographic information.
Client # 2 was admitted on August 15, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated August 15, 2022 to a social service agency allowed for the release of whether the client was in treatment or not. Information documented in the client record released information that exceeded what the release allowed to include social security number and income information.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 1, 2021 annual licensing inspection.
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Plan of Correction
The PD will re-trained staff by December 31, 2022 regarding releasing consistent information according to the items checked off on the release. The release will be re-designed according to new state Confidentiality changes and will have new items to be checked off to release. All employees will be trained on the new release which will also include only releasing information which the client consents to. The PD will continue to conduct chart audits once a month to monitor this specific compliance. |