INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2016 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
A physical plant inspection was conducted on February 19, 2016. Two fire extinguishers maintained by the facility were tagged with an inspection date of April 2014.
This finding was discussed with facility staff during the licensing process.
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Plan of Correction
Inspection was held five days prior to moving the offices to a new site. The fire extinguishers at that site were out of date as a result of the interior being demolished and landlord was not willing to update. New location has updated fire extinguishers on site. Plan is to assure that all fire extinguishers at current site are up to date on inspections. this will be supervised by the Executive Director on a quarterly basis. Extinguishers at current location were inspected on September of 2015 updated inspection is September of 2016. |
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 administrative documentation, the project failed to provide verification that an annual report has been made available to the public.
The findings include:
The project's administrative records were reviewed on February 19, 2016. The facility failed to provide verification that the 2014/2015 annual report had been made available to the public. The project director confirmed that the annual report is made available to the public on the project's website. It was observed that only the 2013/2014 annual report was available on the website at the time of the inspection.
This finding was reviewed with project staff during the licensing inspection.
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Plan of Correction
Executive Director has sent the annual report to our website administrator. The annual report is now available for public view through the website. This became available on 3/23/2016. Executive Director has spoken to website administrator to assure the publication of the annual report on the website on a more timely basis. Executive Director will assure timely publishing of the Annual Report for the public review at the time of completion. Executive Director will assure compliance for the 2015-2016 fiscal year. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the facility failed to document written acknowledgement that the client had been notified of client rights in two of four client records reviewed.
The findings include:
Four client records were reviewed on February 19, 2016. All clients receiving drug and alcohol care or treatment are required to be informed of their rights. Written acknowledgement that the client has been notified of client rights is documented in the client's record. The facility failed to document written acknowledgement that the client has been notified of client rights in client records # 3 and 4.
Client # 3 received an evaluation for drug and alcohol treatment on 10/29/15. Written acknowledgement that the client had been notified of client rights was not documented in the client's record.
Client # 4 received an evaluation for drug and alcohol treatment on 11/18/15. Written acknowledgement that the client had been notified of client rights was not documented in the client's record.
These findings was reviewed with facility staff during the licensing process.
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Plan of Correction
In each case the evaluation was a re-evaluation. The releases were within the time limit however we did not have clients sign a new client rights form. All assessors have been informed by the Executive Director that all clients regardless of whether they are undergoing a re-evaluation or first time evaluation must sign and receive a client right form.
Files will be reviewed on a monthly basis for compliance by the file clerk and report to the Executive Director at the end of the monthly file inspection. The correction will be implemented as of March 21, 2016. |