INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on December 22, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, B.I.Incorporated (Wilkes-Barre) 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of facility staff CPR/first aid certification cards on December 22, 2011, the facility failed to ensure that at least one person trained in CPR skills transported the clients to and from the facility for service
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The findings include:
Based on a review of staff schedules and staff CPR/first aid certification card, the facility failed to provide sufficient CPR/first aid coverage. The facility employs several drivers and none of the drivers are CPR/first aid certified. There are no CPR/first aid trained staff accompanying the drivers.
The program director confirmed that the van drivers were not included in CPR/first aid training.
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Plan of Correction
The facility director will correct this deficiency through several steps. First, no staff will be permitted to operate the facility vehicle until receiving CPR/First Aid training and certification hired after 2/3/12. Starting 2/3/12, only those having the training and certification will operate our vehicle. Second, the facility will offer training to staff on a semi-annual basis, to update certification, have new staff certified, and maintain compliance. Next, training hours for CPR/First Aid will be documented with our training department and expiration dates will be reviewed quarterly by the facility director beginning 3/1/12. Lastly, the facility director will ensure that there is at least one staff during each scheduled shift that is CPR/First Aid certified. This will be completed no later than 2/3/12. |
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 an inspection of the physical plant on December 22, 2011, the facility failed to store trash in covered containers in several of the rooms.
The findings include:
During a physical plant inspection on December 22, 2011 concluded the trash cans in the staff and client bathrooms and the staff dining area failed to include lids on the trash containers as per regulation.
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Plan of Correction
The facility director purchased and installed trash containers with lids on 12/23/11 per regulation. The facility director will be responsible for on-going monitoring of the area in question. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors in four of four client records.
The findings include:
The facility failed to include a current psychosocial evaluation in client record # 3. The client was admitted to the facility on 4-13-2011 and discharged on 6-13-2011. The client was re-admitted to the facility on 6-22-11.
As per regulation, a client who re-enters a facility after a six month period of time requires a new psychosocial. The client was one week over the period of time required to have an update of the present psychosocial. The facility failed to include a new psychosocial evaluation in the client chart.
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Plan of Correction
The facility director will be responsible for ensuring all treatment clients have a psychosocial evaluation completed. This will be accomplished through quality assurance procedures and monthly client file reviews. This will be completed by 01/31/12. |