INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 22, 2010 through December 1, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, A Better Today, 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 and a plan of correction is due on December 29, 2010.
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Plan of Correction
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705.22 (1) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection, survey results and staff interviews, the nonresidential facility failed to maintain the building structure.
The findings include:
Based on a physical plant inspection conducted on November 24, 2010, the windows on the main entrance door were dirty and covered with road grime. Carpets in the reception area, group room and counseling office were worn, torn and stained. A water fountain bowl in the access hallway has been covered with plastic. It appears as though the fountain had been utilized as a place to spit tobacco. The plastic cover had dark thick liquid that had signs of mold. The water fountain condition was discussed with the outpatient staff and facility director on November 24, 2010 and December 2, 2010.
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Plan of Correction
By 06/30/2011 A Better Today, Inc. will have requested licensing approval to relocate to a near by facility that meets all Pennsylvania Department of Health Services criteria and regulations for a non-residential facility with an equivalent outpatient license.
A Better Today, Inc. is a tenant in a building that is maintained through an external ownership group with a lease that stipulates the external ownership group is responsible for all facility maintenance, upkeep, and safety.
In September 2010 A Better Today, Inc. was informed by the private ownership group they will no longer maintain this facility and the building is being sold, although A Better Today, Inc. has requested multiple times that the private ownership group fulfill all agreed upon stipulations of the existing lease. To date this has not occurred.
A Better Today, Inc. is currently involved in discussion with a local leasing entity regarding several appropriate facilities and locations that will meet the Pennsylvania Department of Health Services criteria and regulations for an outpatient facility.
A Better Today, Inc. will take responsibility for thoroughly cleaning windows by January 10, 2011 and will maintain the windows on a weekly basis; this will be done by the facility director.
The facility director will clean and safe guard the existing carpeting, covering all tears and rips. Approved presentation will be ensured by January 10, 2011. The facility director will assure carpet is inspected and maintained on a weekly basis.
The facility will remove all existing covering from the existing fountain. It will then be scrubbed, cleaned, and sanitized. The existing fountain will then be coved by a sanitized covering by January 10, 2011, the fountain will remain out of service. The facility director will inspect and maintain the fountain on a weekly basis.
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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on physical plant inspection results and interviews, the outpatient facility failed to keep the exterior of the building free of hazards.
The findings include:
Based on an inspection of the physical plant and an interview with the outpatient staff on November 24, 2010, the nonresidential facility failed to maintain the exterior of the building. Floor tiles and the cement walk-way at the main entrance door of the facility are loose, missing or cracked, presenting a tripping hazard for patients or staff entering the building.
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Plan of Correction
By 06/30/2011 A Better Today, Inc. will have requested licensing approval to relocate to a near by facility that meets all Pennsylvania Department of Health Services criteria and regulations for a non-residential facility with an equivalent outpatient license.
A Better Today, Inc. is a tenant in a building that is maintained through an external ownership group with a lease that stipulates the external ownership group is responsible for all facility maintenance, upkeep, and safety.
In September 2010 A Better Today, Inc. was informed by the private ownership group they will no longer maintain this facility and the building is being sold, although A Better Today, Inc. has requested multiple times that the private ownership group fulfill all agreed upon stipulations of the existing lease. To date this has not occurred.
A Better Today, Inc. is currently involved in discussion with a local leasing entity regarding several appropriate facilities and locations that will meet the Pennsylvania Department of Health Services criteria and regulations for an outpatient facility.
The facility director has posted caution and warning signs at the entrance to the facility. The facility director has contacted the building owner who has assured A Better Today, Inc. that although they will no longer maintain the building they will handle safety risks by February 15, 2011. |
705.24 (7) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on survey results, interviews and an inspection of the physical plant, the outpatient facility failed to maintain the men's bathroom in a functional, clean and sanitary manner.
The findings include:
A physical plant inspection of the men's bathroom completed on November 24, 2010 revealed dirty and stained floors, walls and plumbing fixtures. Urine odors were present during the inspection of the bathroom facilities in both the men's and women's bathrooms. Interviews with the outpatient staff and the outpatient facility director conducted on November 25, 2010 and December 2, 2010 provided further verification of the lack of maintenance of the bathroom facilities.
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Plan of Correction
By 06/30/2011 A Better Today, Inc. will have requested licensing approval to relocate to a near by facility that meets all Pennsylvania Department of Health Services criteria and regulations for a non-residential facility with an equivalent outpatient license.
A Better Today, Inc. is a tenant in a building that is maintained through an external ownership group with a lease that stipulates the external ownership group is responsible for all facility maintenance, upkeep, and safety.
In September 2010 A Better Today, Inc. was informed by the private ownership group they will no longer maintain this facility and the building is being sold, although A Better Today, Inc. has requested multiple times that the private ownership group fulfill all agreed upon stipulations of the existing lease. To date this has not occurred.
A Better Today, Inc. is currently involved in discussion with a local leasing entity regarding several appropriate facilities and locations that will meet the Pennsylvania Department of Health Services criteria and regulations for an outpatient facility.
The facility director will scrub, clean, and sanitize the bathroom facilities by January 10, 2011. The facility director will ensure a weekly inspection of both the men's and women's facilities to assure cleanliness. |
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 2009 annual report and an interview with the project director, the governing body failed to document the availability to the public of the 2009 annual report .
The findings include:
The 2009 annual report was reviewed on November 23, 2010. The facility is publicly funded and is required to make available to the public an annual report. The 2009 fiscal year ended on December 31, 2009. The project director reports the 2009 annual report was completed in January 2010. The governing body failed to make the 2009 annual report available to the public.
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Plan of Correction
The Executive Director of A Better Today, Inc. will ensure that the availability of the annual report, including the organization's financial statements will be published in the Scranton Times within thirty days of the end of the calendar year.
By January 31 of each calendar year the agency's annual report will be made available to the general public. The availability of that report will be published in the Scranton Times newspaper.
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709.22(e)(2) 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:
(2) A financial statement of income and expenses.
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Observations
Based on a review of the 2009 annual report and an interview with the project/facility director, the governing body failed to make available to the public an annual report which included a financial statement of income and expenses.
The findings include:
The 2009 annual report reviewed on November 23 , 2010 failed to include a financial statement of income and expenses.
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Plan of Correction
The Executive Director of A Better Today, Inc. will ensure that the availability of the annual report, including the organization's financial statements will be published in the Scranton Times within thirty days of the end of the calendar year.
By January 31 of each calendar year the agency's annual report will be made available to the general public. The availability of that report will be published in the Scranton Times newspaper.
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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on an interview with the Facility Director and the review of client census information, the facility failed to comply with the maximum approved capacity for the outpatient treatment activity.
The findings included:
During the annual inspection from November 22, 2010 through December 1, 2010, client census material provided by the Facility Director and an interview with the Facility Director confirmed a current census of 43. The maximum approved capacity is 27.
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Plan of Correction
The Executive Director of A Better Today, Inc. will ensure that all changes to the existing license will be reported within ninety days to the Pennsylvania Department of Health Services utilizing designated forms.
By 01/31/2011 any changes to authorized capacity for any A Better Today, Inc. facility will be forwarded to the Pennsylvania Department of Health Services.
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