INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7-8, 2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Recovery Revolution, Inc., 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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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all trash, garbage and rubbish was stored in noncombustible, covered containers that prevent the penetration of insects and rodents.
The findings include:
A physical plant inspection was conducted on January 8, 2016 at approximately 9:00 AM. Three trash containers were observed outside the back door during the physical plant inspection. One of the containers was not covered and a lid was not observed on the facility grounds.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The lid to the one of three facility trash can was missing. It had either blown away or been stolen. The Executive Director on January 13, 2016 bought a brand new trash can with a lid and removed the old trash can without a lid.
While doing the monthly walk-through, Executive Director will assure that the lids are on all trashcans. In addition, a trashcan with an attached lid was purchased. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document client orientation to the project as part of the intake procedure in seven of ten client records.
The findings include:
Ten client records were reviewed on January 7-8, 2016 for documentation of client orientation.
Client #2 was admitted to the facility on July 22, 2015 and was discharged on December 11, 2015. There was no documentation of client orientation in the client record.
Client #3 was admitted to the facility on June 23, 2015 and was discharged on September 10, 2015. There was no documentation of client orientation in the client record.
Client #5 was admitted to the facility on October 12, 2015 and was discharged on December 31, 2015. There was no documentation of client orientation in the client record.
Client #6 was admitted to the facility on July 15, 2015 and was discharged on December 21, 2015. There was no documentation of client orientation in the client record as of the date of the licensing inspection.
Client #7 was admitted to the facility on June 15, 2015 and was an active client at the time of inspection. There was no documentation of client orientation in the client record as of the date of the licensing inspection.
Client #8 was admitted to the facility on July 16, 2015 and was an active client at the time of inspection. There was no documentation of client orientation in the client record as of the date of the licensing inspection.
Client #10 was admitted to the facility on November 13, 2015 and was an active client at the time of inspection. There was no documentation of client orientation in the client record as of the date of the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
When the facility moved from paper charts to Electronic Medical Record (EMR), the Executive Director failed to tell the clinical staff where the orientation form was in the new system, thus it was not completed globally. On 1/11/2016, the Executive Director requested our EMR system to add the orientation form to the Consent to Treatment form, thus consolidating the two forms. The form now reads Consent to Treatment/Orientation Form. On 1/12/2016, the Executive Director held a staff meeting to address the new consolidated form in the EMR system in which the staff member completing the intake will review with client and and sign upon intake into the program. |