INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 26 - 28, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Habit OPCO, Inc. - Pottstown 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.
|
Plan of Correction
|
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that there were no heaters located within the facility that were not permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on August 26, 2014.
A portable space heater that was not permanently mounted or installed was observed in a first floor counselor's office. The counselor's office was the first office on the left of the record room hallway.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Specific counselor in violation was addressed about having a portable heater in the office, immediately upon notification of such. Facility Director will place this on the staff meeting agenda for review. The next scheduled staff meeting will be on October 21, 2014. Ongoing monitoring for portable heaters will occur during monthly physical plant checks by the security associate to prevent future violations. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
|
Observations
Based on a physical plant inspection, the facility failed to clearly indicate exits by the use of signs.
The findings include:
A physical plant inspection was conducted on August 26, 2014. The facility failed to clearly indicate an emergency exit at the main entrance.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Exit sign was adjusted to clearly indicate the appropriate exits, immediately upon notification of the deficiency. Ongoing monitoring will occur during monthly physical plant checks by the security associate to prevent future violations |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
Based on a review of the facility's fire drill log, the facility failed to conduct fire drills on different days of the week and at different times of the day.
The findings include:
On August 26, 2014, the facility's fire drill log was reviewed covering the period of October 24, 2013 through July 24, 2014. The facility failed to conduct fire drills on different days of the week and at different times of the day. The facility conducted eight of nine fire drills on Thursday within the eleven o'clock hour.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beginning with September 2014, this facility will conduct fire drills on various days/times throughout the year on a monthly basis. Administrative Assistant will develop a schedule of such for the year, which will be documented accordingly in the fire drill log. Facility Director will oversee compliance through review of fire drill log. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
|
Observations
Based on a review of administrative documentation, including the 2013 annual report, the governing body failed to include a financial statement of income and expenses in the 2013 annual report and failed to verify that the annual report was made available to the public.
The findings include:
Administrative documentation, including the 2013 annual report, was reviewed on August 26, 2014. The governing body failed to include a financial statement of income and expenses in the 2013 annual report and failed to verify that the annual report was made available to the public.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The 2014 annual report will be inclusive of a financial statement of income and expenses and will verify that the annual report was made available to the public. Facility Director will consult with Regional Director to ensure this information is incorporated and documented appropriately in the annual report. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
|
Observations
Based on a review of client records, the facility failed to document a proposed type of support service in five of sixteen individual treatment and rehabilitation plans.
The findings include:
Sixteen client records were reviewed on August 26 - 28, 2014, for documentation of a proposed type of support service in the individual treatment and rehabilitation plan. The facility failed to document support services in five of sixteen client records reviewed, specifically client records # 3, 4, 5, 12 and 13.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Treatment plans requirements were reviewed with all counselors, specifically indicating the addition of support services to each plan as needed and to also indicate this was reviewed, should support services be deemed unnecessary at that particular time. In addition, an IT ticket was submitted and closed on 9/19/14, which added a category specific to addressing support services in the "general notes" section of the plan. This will be reviewed again with all counselors at the 10/21/14 staff meeting. CD or designated staff will review treatment plans accordingly to ensure support services are being addressed. |