INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 13, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on November 13, 2006.
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Plan of Correction
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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
In 2 out of 4 personnel records reviewed, specifically #2 and 3, there was no documentation indicating that staff were instructed in the use of the fire extinguisher upon employment.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
In 2 out of 4 personnel records reviewed, specifically #2 and 3, there was no documentation indicating that staff were trained to perform assigned tasks during emergencies.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
There was no documentation indicating that a fire drill was conducted during sleeping hours at least every 6 months.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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
In 3 out of 3 client records reviewed, specifically #1, 2 and 3, the HIPAA privacy policy form violates federal confidentiality regulation 42 CFR and does not inform the client that drug and alcohol confidentiality regulations may prohibit releases of information that could be permitted by the HIPAA regulations. In addition, the consent to release information form from CBH is invalid in that it states that Family House may communicate with CBH while failing to indicate what would be communicated and a parent/guardian signature is incorrectly required for clients under the age of 14 years.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
In client record #1 and 3, the consent to release information form indicated that information exceeding the limitations imposed by 4 Pa. Code subsection 255.5 was released to Probation Officers and managed care entities. The information released included urinalysis results and medications. In client record #3 a consent to release information form did not indicate what information was to be released.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
In 3 out of 4 client records reviewed, specifically #1, 3 and 4, the physical examinations did not include documentation of vital signs, general appearance of the patient or the physician's impressions.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
In 3 out of 4 client records reviewed, specifically #1, 3 and 4, the psychosocial evaluation was disjointed with very little pertaining to clinical opinions or impressions.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
There was no follow-up conducted on the client after termination from treatment in 1 out of 2 client records reviewed, specifically client record #2.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |