INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 21-22, 2017, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago - Pottsville 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) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of facility records conducted during the onsite inspection, and based on staff interviews conducted during the onsite inspection, the facility failed to ensure that the monthly fire drills were unannounced.
The Staff Meetings Agenda Minutes dated 02/15/2017, listed the date and shift of the fire drill conducted on 02/21/2017.
The Staff Meetings Agenda Minutes dated 03/02/2017, listed that date and shift of the fire drill conducted on 03/27/2017.
The Staff Meetings Agenda Minutes dated 04/26/2017, listed that date and shift of the fire drill conducted on 04/28/2017.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The fire drills will no longer be announced during the monthly staff meeting. Only the lead monitor will know the date and time of the fire drill beginning on 09-25-17.
The lead monitor will conduct the unannounced monthly fire drill for the facility to ensure compliance beginning on 09-25-17.
The facility director will monitor and review the monthly fire drill log to ensure completion and ongoing compliance beginning on 09-25-17.
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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 13 client records conducted during the onsite inspection, the facility failed to provide the required notification for clients involuntarily discharged in 1 of 1 applicable records reviewed.
Client #10 was admitted for treatment on 05/12/2017, and was involuntarily discharged on 07/06/2017, but the facility did not provide the client with written documentation of the reason for the involuntary discharge.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The clinical supervisor will send written documentation to client #10 by sending a copy of their involuntary discharge by 10-11-17. The involuntary discharge will contain written documentation for the reason or reasons for the client's involuntary discharge.
The clinical supervisor will retrain all clinical staff on the appropriate completion of the Notice of Termination form during clinical meeting on 09-25-17.
The facility counselors will monitor appropriate completion via weekly client chart reviews beginning on 09-29-17.
The clinical supervisor will monitor ongoing compliance through regular monthly client chart audits beginning on 09-29-17.
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