INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Outside In School of Experiential Education, 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
The facility failed to ensure that emergency exits were unobstructed based on a physical plant inspection conducted on March 20, 2017 at approximately 9:15 AM.
The facility's front door/emergency exit has a double-keyed deadbolt lock. This lock would prevent this exit from being operable at all times.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director notified building maintenance on March 20, 2017 that the double keyed deadbolt on front door needed to be replaced with a single cylinder deadbolt. Building maintenance replaced the lock on Friday, March 24, 2017. |
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
The facility failed to obtain an informed and voluntary consent from the client prior to the release of information in one of seven client records reviewed during the annual licensing inspection conducted on March 20, 2017.
Client # 7 was admitted on June 1, 2016 and discharged on September 14, 2016. The client's name and summary of treatment was disclosed by fax to an agency on June 15, 2016.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counseling staff will participate in documentation training conducted by Clinical Supervisor on April 12, 2017. This training will review confidentiality and consent for disclosure of information. The training will detail how to document consents and verify that all releases are signed by client prior to release of information. Reviews of the record will be conducted by the clinical supervisor. All treatment records from April 15, 2017 will be in compliance. |