INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on December 9, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Diakon Family Life Services 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, there was a fire extinguisher observed in the rear of the office that had expired in November 2020.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
705.28(c)(3) was reviewed with the Director of Administrative Operations. The agency used to service the facility fire extinguishers was contacted to schedule service. The Director of Administrative Operations will schedule and arrange for automatic yearly service to ensure compliance with 705.28(c)(3). Compliance with this standard will be monitored and enforced by the Facility Director. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in client record # 2. Also, the information released was beyond Pa code 255.5 for a government agency.
Client # 2 was admitted on January 21, 2020 and was still active at the time of the inspection. Correspondence with a government agency released information dated October 29, 2020 without an informed and voluntary consent form from the client. The information released included : treatment plans, psychiatric evaluation, and psychosocial.
A separate correspondence dated February 12, 2020 was addressed to: "To whom it may concern" documenting admission to treatment.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.28(c) The Facility Director provided training to the clinical staff that outlined § 709.28(c) Confidentiality. The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. Voluntary consents for disclosure of any information shall be obtained by clients and documented in the client record prior to the disclosure of information. Compliance with this standard will be monitored and enforced by the Facility Director. |