INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 25-27, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Marworth 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill record submitted during the presubmission process, and facility fire drill record, reviewed during the onsite inspection, the facility failed to document all of the required information on its fire dill forms.
The fire drills were reviewed from July 1, 2016 through June 30, 2017 and did not have documentation on what evacuation routes used during the fire drills.
These findings were reviewed with the facility staff as part of the onsite inspection.
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Plan of Correction
The floor plan has been added to the fire drill evaluation to include the location of the fire and the blocked exits near the fire. "All other exits will then be available for egress from the facility other than the exits blocked by the fire". This statement will be documented on the fire drill record log.
The security supervisor is responsible for filling out the fire drill evaluation and floor plan.
He was trained on the procedure on 7/28/2017. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's fire drill forms submitted during the presubmission process, and the facility's fire drill forms, reviewed during the onsite inspection, the facility failed to document all of the required information in its fire drill records.
The fire drills were reviewed from July 1, 2016 through June 30, 2017 and did not have documentation on what evacuation routes used during the fire drills.
These findings were reviewed with the facility staff as part of the onsite inspection.
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Plan of Correction
The floor plan has been added to the fire drill evaluation to include the location of the fire and the blocked exits near the fire. "All other exits will then be available for egress from the facility other than the exits blocked by the fire". This statement will be documented on the fire drill record log.
The security supervisor is responsible for filling out the fire drill evaluation and floor plan.
He was trained on the procedure on 7/28/2017. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of 24 client records during the onsite inspection, the facility failed to ensure that a treatment plan was updated at least once every 60 days in four of six outpatient records.
Client # 21 was admitted for outpatient treatment on 06/29/2015, and discharged on 05/18/17. The client's treatment plan had an update documented on 01/27/2017, but the next update was not completed until 05/05/2017.
Client # 22 was admitted for outpatient treatment on 03/19/2015, and discharged on 02/06/2017. The client's treatment plan had an update documented on 10/14/2016, but the next update was not completed until 01/27/2017.
Client # 23 was admitted for outpatient treatment on 07/14/2016, and discharged on 06/21/2017. The client's treatment plan had an update documented on 01/23/2017, but the next update was not completed until 06/02/2017.
Client # 24 was admitted for outpatient treatment on 01/05/2017, and discharged on 07/13/2017. The client's treatment plan had an update documented on 02/10/2017, but the next update was not completed until 04/20/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
During weekly supervision and Multi-disciplinary Treatment team meetings; counselor charts will be reviewed for compliance of the 60 day requirement for case consultation notes.
All counselors will be re-educated regarding the 60-day requirement for case consultation notes of the treatment plan review and update.
15 charts will be reviewed per month for 6 months to verify compliance with the standard, and 8 charts will be reviewed monthly thereafter to assure continued compliance with the standard.
Director of Outpatient programs will be responsible for the education by 8/18/2017 and he will also be responsible for the ongoing chart review for the next 6 months.
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