INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 25, 2008 and August 26, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitation Services, 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 and a plan of correction is due on September 29, 2008.
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Plan of Correction
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705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a review of the physical plant on August 25, 2008, the facility failed to secure a railing on an outside porch with a drop of over 18 inches.
Finding:
The door leading to the porch is used an a means of egress from the facility and the porch steps did not have secure hand railing.
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Plan of Correction
Private contractor will be contacted by Project Director to install a railing on the porch. The installation of this railing will be completed within 30 days following inspection. Staff will insure that clients exit the porch using the stairs and monitor the area so that no clients are permitted to linger in the area that currently does not have a railing. |
709.28(c)(3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of twelve clients records on August 26, 2008, eight were reviewed for consent to release information forms. The facility failed to document the specific purpose of disclosure on the consent to release information form for eight of eight records where required.
Finding:
The consent to release information forms contained generalized and uniform information rather than the specific information that was to be released in client records #1, 2, 3, 4, 5, 6, 7, and 10.
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Plan of Correction
Facility Director and Clinical Supervisor met with the clinical team to discuss the proper documentation of confidentiality forms. It was determined that the existing forms will remain; however, clinical staff will document the specific purpose of the consent on all confidentiality forms. This purpose will vary based on the intended purpose of the consent. Clinical Supervisor will continue to monitor and train staff to ensure the forms do not contain generalized and uniform information. |