INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 17-18, 2018 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, Huntington Creek Recovery Center was found to not 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
The facility failed to maintain a fire drill record that included the exit route used and the number of persons in the facility at the time of the inspection.
The facility failed to document the exit(s) used in all fire drills recorded between October 17, 2017 and September 28, 2018.
The facility failed to document the number of persons in the facility at the time of the drill on the following dates; December 18, 2017, June 27, 2018 and August 29, 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Director of Compliance, along with facility director educated maintenance staff regarding the correct procedures in completing documentation related to fire drill. Discussion was focused on the importance of recording the exit used and number of persons in the facility at the time of each drill. Both the director of compliance as well as facility director will monitor the documentation monthly to ensure the fire drill are appropriately documented moving forward. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to conduct a fire drill during sleeping hours at least every six months.
The facility failed to have any fire drills during sleeping hours from October 17, 2017 through September 28, 2018.
This was a repeat citation from November 7, 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and compliance director educated maintenance manager about the need for fire drill during sleeping hours every six months. On 10/22/18 a fire drill was conducted at 5:30 am, which is during sleeping hours. Quality assurance staff member will be monitoring fire drills at the facility to ensure compliance with this standard moving forward. The monitoring will be held monthly and fire drills will be scheduled in advance to ensure full compliance. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
The facility failed to conduct fire drills on different days of the week.
The facility conducted seven out of twelve fire drills on Wednesdays, from October 17, 2017 through September 28, 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Compliance director has assigned fire drill maintenance to quality assurance staff member. Fire drills will be scheduled each month by quality assurance staff. The compliance Director will oversee the scheduling of monthly fire drills to ensure they are scheduled on different days of the week. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
The facility failed to list ethnicity in the client rights policy.
Clients # 8-14 signed off on the facility's client rights policy, however it did not include ethnicity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Quality assurance staff corrected the form which includes client rights. The word "ethnicity" was included in the patient rights form. clients 8-14 were discharged at the time of these changes. Charts are monitored weekly by quality assurance staff. QA staff will ensure that the corrected form is used for each new client. |