INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17, 2009 through December 18, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Harwood House 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 January 16, 2009.
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Plan of Correction
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709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records and a staff interview, the facility failed to document a written notification of termination in one of one client record.
The findings include:
Six client records were reviewed on December 18, 2009. Of those six clients, only one client was involuntarily terminated. There was no documentation that the facility had notified the client, in writing, of a decision to involuntarily terminate the client in client record #4.
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Plan of Correction
it is the responsibility of the staff on duty at time of involuntary termination of treatment to document involuntary discharge. Involuntary notice discharge forms will be included in admission packet.
All staff will be trained on proper discharge documentation by 1/18/10.
It is the responsibility of the clinical supervisor to ensure that the notice of involuntary discharge information is documented in the chart. It is the responsibility of the program director to ensure overall compliance. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection and staff interview, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Farenheit.
The findings include:
A physical plant inspection was conducted on December 17, 2009 at approximately 1:20 PM. The hot water in the kitchen sink registered at 142 degrees Farenheit. The hot water in the men's bathroom registered at 140 degrees Farenheit. The project director noted she would have maintenance check the hot water heater and adjust the temperature to below 120 degrees Farenheit. The licensing specialist tested the hot water temperature on December 18, 2009 at approximately 9:30 AM. The hot water in the kitchen sink registered at 136 degrees Farenheit. The hot water in the women's bathroom registered at 140 degrees Farenheit. The licensing specialist checked the hot water temperatures again at 11:00 AM on December 18, 2009. The hot water in the women's bathroom registered at 142 degrees Farenheit.
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Plan of Correction
Designated staff on duty is responsible to ensure hot water temperature does not exceed 120 degrees. plumber will set temperature knobs. staff will document water heaters checked daily.
Clinical supervisor is responsible for ensuring that all staff are trained in checking temperature knob and in documentation of date checked.
program director will ensure overall compliance.
All staff will be trained in temperature check by 1/18/10.
Completed: 3rd shift staff persons were trained and in compliance. |
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
Based on a review of fire drill records and a staff interview, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings include:
Fire drill records were reviewed on December 17, 2009. The only fire drill conducted during sleeping hours since the previous licensing inspection in December of 2008 was conducted on February 24, 2009. In speaking with the project director, it was confirmed that no other fire drills were conducted during sleeping hours.
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Plan of Correction
The staff on duty is responsible for conducting fire drill during sleeping hours and for proper documentation.
Clinical supervisor is responsible for ensuring that staff conduct the fire drill at least every 6 months.
Program director is responsible for overall compliance.
Staff on duty have been notified of fire drills during sleeping hours and trained in fire drill compliance |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records and a staff interview, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
Fire drill records were reviewed on December 17, 2009. The only fire drills conducted that showed documentation that a fire alarm or smoke detector was set off were dated June 29, 2009 and September 4, 2009. In speaking with the project director, it was confirmed that the fire alarm or smoke detector was not set off during any other fire drills that were conducted since the previous licensing inspection in December 2008.
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Plan of Correction
The staff on duty is responsible for sounding fire alarm or responding to fire alarm during fire drills and in documentation of fire drill, including which smoke detector sounded.
Clinical supervisor is responsible for ensuring that staff properly conduct and document fire drills.
Program Director is responsible for overall compliance.
All staff will be re-trained on conducting and documentation of fire drills by 1/18/10. |