INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 20, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Genesis House - Bloomsburg 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 23, 2008.
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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
Based on an inspection of two bathrooms located in the office suite, the nonresidential facility failed to provide a wall mirror in one of the two bathrooms.
Findings:
The bathroom located in the group room did not have a wall mirror installed.
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Plan of Correction
Project director has authorized the purchase and installation of a mirror in the group bathroom on 8/29/08.
Facility director has purchased and installed the mirror on 9/2/08. Issue corrected on 9/2/08. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential 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 an inspection of the facility and an interview and discussion with the project director and building manager on August 20, 2008, the nonresidential facility failed to install a secure handrail on an interior ramp at the main entrance to the building.
Findings:
The ramp at the main entrance is in excess of eighteen inches and did not have a secure hand rail. The ramp is fourteen feet long, fourteen feet wide with a rise of in excess of eighteen inches.
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Plan of Correction
Project director met with building manager on 8/20/08 along with licensing inspector to request installation of appropriate hand rail on interior ramp at main building entrance.
Building manager installed the appropriate hand rail on the ramp on 8/26/08. Issue corrected on 8/26/08. |
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 client records on August 20, 2008, the project failed to obtain informed and voluntary consents to disclose information from the client record that included the purpose of the disclosure.
Findings:
Three of five consents to release information in two of four client records reviewed on August 20, 2008 did not include the purpose of the release of information from the client record.
Two of the three consents to release information in client record # 1 did not define the purpose for the release of information.
One of two consents to release information in client record # 1 did not define the purpose of the release of information.
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Plan of Correction
Project director will retrain the agency staff on the appropriate completion of client consent to release information forms; specifically reviewing the documentation of the purpose for information release, during the weekly staff meeting on 9/5/08.
Facility director will review compliance during weekly chart reviews and will discuss any issues with compliance with the project director by 9/26/08.
Project director will complete random chart reviews on 9/26/08 to ensure compliance. |