INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 23-26, 2019 by staff from the Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site complaint investigation, New Directions was found not to 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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705.23 (2) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Base on observation of the physical plant while conducting a complaint investigation the facility failed to maintain furnishing in good repair.During the complaint investigation it was observed that four of the waiting room chairs had ripped and torn fabric.
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Plan of Correction
The Director of Operations will replace all of the chairs in the waiting room, including the four that have been identified as "ripped and torn," by October 1, 2019. On a bi-weekly basis, the Director of Operations will inspect all of the chairs in the waiting room to ensure that this deficiency does not occur again. |
715.7(b) LICENSURE Dispensing or Administering Staffing
(b) Dispensing time shall be prorated for patient census. There shall be sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.
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Observations
Based on staff and client interviews, the facility failed to provide sufficient dispensing staff to ensure that all patients are medicated within 15 minutes of arrival at the dispensing area.During the complaint investigation it was discovered during interviews that there was a shortage of staff and this was the reason for the long dosing times.
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Plan of Correction
By September 26, 2019, the Nurse Manager will have completed the hiring of additional staff to ensure that clients are medicated within 15 minutes of their arrival at the dispensing area. |