INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Men and Women for Human Excellence was found to be not 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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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
A physical plant inspection was conducted on July 19, 2017. The facility failed to ensure that the restroom, in the center hallway at 2600 Cecil B. Moore Ave., was equipped with a mirror, paper towels or a mechanical dryer.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
MWFHE,Inc' Maintenance Supervisor will immediately install the following items to the restroom in the center hallway at 2600 Cecil B. Moore Ave building: 1)wall mirror,and 2) paper towel dispenser. The Program Director will follow-up and review installation of these items to ensure completion. The Program Director will train and designate the Maintenance Supervisor to make daily rounds to ensure that the restrooms are clean and contain all required item, as per
#P195. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
A physical plant inspection was conducted on July 19, 2017. The facility failed to ensure that the restroom water temp was maintained below 120 degrees.
The hot water temperature in the bathroom, in the center hallway at 2600 Cecil B. Moore Ave., was measured at 154.2 degrees.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Program Director will instruct the Maintenance Supervisor and staff on making daily(early morning)rounds to ensure that the water temperature in all restrooms is maintained below 120 degrees.The Program Director will also conduct random checks to ensure compliance with this regulation. All maintenance staff monitoring compliance with this regulation will be required to indicate the temperature and sign off on the temperature log form. |
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
Seven client records were reviewed on July 19, 2017. The facility failed to document a valid consent to release information form in client records, #4 & 6.
Client #4 was admitted on 1/5/17 and was discharged on 5/24/17. A fax transmission dated 4/19/17 to an agency was documented in the record, but no consent to release was documented at the time of the licensing inspection for that agency.
Client #6 was admitted on 8/19/16 and was discharged on 4/26/17. Urine drug screen results from a laboratory dated 12/13/16, 12/19/16, 12/28/16, 1/3/17, 1/17/17 and 1/24/17 were documented, however there was no consent to release for this agency.
This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor will conduct a training on "client confidentiality"and emphasize the importance of reviewing consents carefully before releasing any client information to a given source. The Quality Assurance Specialist will also randomly review records to ensure that there are client consents for any information being released from the client's record.
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