INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Lehigh Valley Drug and Alcohol Intake Unit 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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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
The findings include:
A physical plant inspection was conducted on March 26, 2014, at approximately 2:50 PM. It was observed that the facility had two exits; however the second emergency exit was obstructed as it was behind a closed and locked door.
The Project Director confirmed the findings. He stated that he did not have the key to access the emergency exit.
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Plan of Correction
Executive Director will contact Landlord by April 15, 2014 to discuss locked door preventing access to the exit. Solution will be to provide access to this access at all times. Executive Director will include this exit during every other month fire drill to assure continual access to the secondary exit.
As of April 15, 2014 the second exit has become accessable. Fire drills will be conducted via the secondary exit on every other month drill. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire drill log, the facility failed to prepare alternate exit routes during fire drills.
The findings include:
The facility's fire drill log for the time frame of May 24, 2013 to March 6, 2014 was reviewed on March 26, 2014.The facility failed to alternate exit routes during all fire drills conducted from May 24, 2013 to March 6, 2014 . The facility only documented the use of the front exit for all of the fire drills referenced above. In addition, it was observed and confirmed that the facility did not have access to the second emergency exit as it was obstructed behind a closed and locked door.
The Project Director confirmed the findings.
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Plan of Correction
Executive Director will contact Landlord by April 15, 2014 to discuss locked door preventing access to the exit. Solution will be to provide access to this access at all times. Executive Director will include this exit during every other month fire drill to assure continual access to the secondary exit.
Executive Director will alternate fire drill exits from the front to the back exit. Start date will be the last week in April 2014. Executive Director will assure compliance with fire drill alternate exit mandate.
The door has been connected to the alarm system and will open when the alarm is activated. Landlord has installed an electric override to utilize when we have fire drills, to assure that the door is working properly. |
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:
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Observations
Based on a review of the annual report and the facility's web-site, the governing body failed to make available to the public an annual report which included a financial statement of income and expenses, and a statement disclosing the names of officers, directors, and principal shareholders.
The findings include:
The facility's 2012/2013 annual report and the web-site were reviewed on March 26, 2014. The facility failed to include a financial statement of income and expenses, and a statement disclosing the names of officers, directors, and principal shareholders in the 2012/2013 annual report. The facility also failed to make the 2012/2013 annual report available to the public.
The Project Director stated that the current annual report was available to the public on the facility's web-site. However, only the 2011/2012 annual report was available on the web-site at the time of inspection.
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Plan of Correction
Executive Director will include a financial statement in the annual report to be completed by April 23, 2014. Executive Director will contact the website manager to discuss the abscence of the annual report on the website by April 12, 2014. Executive Director will check to assure the annual report has been placed on the website for public viewing. Expected date of completed annual report to include the financial statement is April 23, 2014. Executive Director is repsonsible for the report and will assure compliance through visually monitoring the website for the annual report in the future. The results of the physical checking of the website for the report documented in the administrative meeting notes. This completed report will be available to the public by April 23, 2014. This annual report will include a statement explaining that the Intake Unit is a sole proprietership, meaning there is no board of directors or shareholders. To ensure that this deficiency will not occur in the future; the do date of the annual report will be added to the Quality Assurance team and Administrative Team list of due dates and follow-up oversight. The annual report will be part of the fourth quarter monitoring review. The Quality Assurance team will also view the website to ensure that the updated report has been posted, they will add this to the quality assurance bench mark data. This will provide multiple oversight to assure full compliance of the annual report on a yearly basis. |
709.44(b)(1) LICENSURE Physical Examination
709.44. Client records.
(b) If applicable, the project shall also include the following items in the client record:
(1) Results of physical examination.
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Observations
Based on a review of client records, the facility failed to document follow-up information in two of two client records.
The findings include:
Two client records requiring documentation of follow-up information were reviewed on March 26, 2014. The facility failed to document follow-up information in client records # 2 and 4.
Client # 2 was evaluated on 1/27/14. Client # 2 was referred to an outside agency and was placed on a waiting list. The facility failed to attempt follow-up for client # 2.
Client # 4 was evaluated on 1/7/14. Treatment was pending for client # 4 at the completion of the intake. The facility failed to attempt follow-up for client # 4.
The Project Director confirmed that follow-up was not conducted for clients #2 and 4.
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Plan of Correction
Clinical Director will meet with all assessment specialist by April 23, 2014 to instruct them on the need to document follow up information on clients referred for treatment. Quality Assurance will be directed by the Program Director to include monitoring of follow-up documentation in client files. Report from the quality assurance staff member will be provided to the Program Director on a quarterly basis to assure compliance. Any non compliance will result in supervision from the Program Director for additonal instruction and montoring until full compliance is achieved. Complinace report will be provided to the administrative team on a quarterly basis first report will be at the June 2014 administrative meeting. |