INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 16, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site investigation, Conewago was found to not be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
The facility failed to ensure the building was safe and free from damage. Based on a physical plant inspection of the detox unit, a large hole was observed in the wall next to a client's bed in bedroom #103.
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Plan of Correction
The hole was repaired in bedroom #103 by facility maintenance staff on May 17, 2019. The maintenance staff will complete a daily walk through of each floor of the facility. During the walk through, the staff will inspect each bedroom and group room thoroughly for any damage. If any damage is found, it will be fixed in a timely manner. The facility is in full compliance as of May 17, 2019. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure privacy of counseling sessions. Based on a physical plant inspection, cameras were observed in the second and third floor male and female group counseling rooms.
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Plan of Correction
The maintenance staff will remove the cameras from the male and female group counseling rooms no later than June 30, 2019. The facility director will continue to ensure privacy of counseling sessions. |