INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on January 22, 2020 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, HABIT OPCO, Inc, - Allentown was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
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
During the complaint investigation, the facility failed to ensure that all heaters were mounted or installed.
There was a heater located in the facility director's office.
This was addressed with facility staff during the complaint investigation.
|
Plan of Correction
The Health and Safety Liaison removed the heater from facility director's office on January 22, 2020. Clinic Director will ensure that if there is a space heater in any room, it is in compliance with the DDAP requirement for heater to be mounted or installed. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on an interview with facility staff, the facility failed to provide documentation to DDAP that there was police presence on site at the facility. The date of the police presence was May 13, 2019.
This was discussed with staff during the complaint investigation.
|
Plan of Correction
The Clinic Director,
Quality & Compliance
Department staff as well as with
the Clinical Support and
Compliance staff members to
review the existing policies and
procedures and ensure that
language is in place to address
unusual incidents involving an
event at the facility requiring
the presence of police, fire, or
ambulance personnel.
In the event of an unusual incident involving the presence of police, fire or ambulance personnel at the facility, staff will complete the incident report with 24 hours or less, share with clinical supervisor within 48 or less, then give to clinic director to file with DDAP by the third day, at the latest.
Additionally, such will be followed up at the full staff meeting March 2020 and training to review the policies and
procedures.
|