INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24 - 25, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Snug Harbor Rehabilitation and Recovery LLC 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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705.10 (b) (4) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(4) Maintain a manual fire alarm system that is audible throughout the facility in a residential facility where four or more residents reside.
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Observations
Based on a physical plant inspection conducted with maintenance staff on March 24, 2022, at approximately 9:15 AM, the facility failed to maintain a manual fire alarm system that included manual pull stations.
No manual pull stations were observed during the physical plant inspection of cottages 1 and 3. This was confirmed by facility maintenance staff.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
We have contacted our fire and safety monitoring company.
Thay have ordered the equipment necessary for compliance with this regulation.
The date of installation has not been confirmed due to unknown product availability/ delivery.
Property Manager will be responsible for coordination of this installation.
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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.
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Observations
Based on a review of client records, the facility failed to document a written, informed and voluntary consent from the client prior to the release of information contained in the client record in one of twelve records. In addition, the facility exceeded the limitations imposed at 4 Pa. Code 255.5 when releasing information to a government agency in client record # 6.
Client # 6 was admitted December 10, 2021, and discharged December 19, 2021. The following information was faxed to a government agency on January 13, 2022, without client written consent and exceeded 4 Pa. Code 255.5: urinalysis, treatment plan, intake packet and discharge forms.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This request for information occurred after discharge from our facility.
Staff will be reeducated on our ROI procedures after discharge as well as the information to be shared which is limited to our policy regulation 709.51/709.62.
The staff will be reeducated on this procedure by Executive Director.
The staff will be educated on retaining copies of ROI from outside sources for client record in addition to internal ROI. Both will be maintained within the client record.
Random client chart audits are performed by the Program Manager.
Our QAPI Manager is responsible for the final chart inspection ensuring all documents are enclosed. This monitoring is ongoing monthly. |