INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 13, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Bucks County Counseling 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 (d) (2) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(2) Conduct fire drills during normal staffing conditions.
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Observations
A review of the August 2016 through August 2017 fire drill logs was conducted during the licensing process. The facility failed to conduct fire drills during normal staffing conditions during the months of November 2016, March 2017 and May 2017. The facility conducted fire drills on Saturdays which are not the facility's posted days of operation.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
All staff will receive training on 705.28. Fire safety. (d) Fire drills. Training will be completed by 10/1/17. Project manager is responsible.
Fire drill log sheet will be modified to indicate day of week of fire drill as well as time of day. A separate column will be added to indicate it was checked to be sure it was during the posted normal staffing hours. Item will be completed by 10/1/17, project manager is responsible.
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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 the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 1 of 7 client records. Additionally, 1 of 7 client records had consent to release forms that did not include the dated signature of the witness.
Client #2 was admitted on 1/3/17 and was still an active client at the time of the inspection. There was a consent to release information form to a physician signed and dated by the client on 2/20/17; however, there was no dated signature of the witness.
Client #3 was admitted on 7/18/17 and was still an active client at the time of the inspection. There was documentation of family counseling sessions with the client's children and significant other on 8/3, 8/21 and 8/24; however, there were no proper consent to release information forms on file as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff will receive training on Pa Code 255.5, Federal code 42 C.F.R. and § 709.28. Confidentiality. Training will be completed by 10/1/17, project manager is responsible. Going forward, project manager will inspect all releases to insure proper signature is in place.
The incident listed under Client #3 occurred when client unexpectedly arrived for individual session with family in tow. The above mentioned training will specifically addresses such occurrences. Training will be completed by 10/1/17, project manager is responsible
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