INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 2, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, James A. Casey House, LLC 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential 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 a physical plant inspection on August 2, 2022, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as three bags of rubbish were besides the garbage cans in the rear of the building. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The support staff supervisor shall ensure that all garbage is placed in covered containers. The support staff supervisor will assign a support staff member to perform a daily inspection of the dumpster area to ensure compliance. Signs will be posted in the dumpster area stating that all trash and recyclables are to be placed in the dumpster. The Project Director will provide oversight. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection on August 2, 2022, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom as neither were in any client bathroom. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 8/24/22 all client and public bathrooms have been stocked with paper towels. All clients have been notified by the Project Director to request paper towels from any support staff member as needed. Also, as a part of their daily walk-through inspections, facility support staff will ensure that all bathrooms have paper towels and will immediately restock paper towels as needed. The support staff supervisor will provide oversight and will be responsible for monitoring ongoing compliance and will ensure that sufficient paper towels are on hand and are available to clients at all times. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) 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, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
The facility failed to document that the annual report for 2021 was made available to the public.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall ensure that the facility annual report for the prior year is posted on the official facility website by no later than 31 January of the current year. The most recent annual report, for the calendar year 2022, will be posted on the facility website no later than 1 September 2022. Quality Assurance staff have been instructed to add the report to their December calendar and to remind the Project Director to post the annual report by 31 January of the upcoming year. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a discussion with facility staff, the facility failed to follow the exception granted to them for the annual financial audit. The facility did not ensure that the tax information was onsite and available for review during the onsite annual inspection or during the licensing process. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director shall ensure that the annual audit is available during annual DDAP inspections. Upon notification of future DDAP inspections, the Project Director will request a copy of the most recent audit from the facility owner and/or his accountants so that it will be available for review during the inspection. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include follow-up information in two of two applicable records reviewed. Client #1 was admitted on December 31, 2021 and was discharged on May 16, 2022. The client record did not contain documentation of follow-up information.Client #2 was admitted on March 11, 2022 and was discharged on May 18, 2022. The client record did not contain documentation of follow-up information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor shall ensure that here is at least one attempt to follow-up on all clients regardless of type of discharge. Quality Assurance staff will monitor all discharges to ensure that a follow-up is documented in all client charts. The Clinical Supervisor will provide a training session to clinical staff regarding follow-ups and associated documentation no later than 15 September 2022. The Project Director will provide oversight to ensure compliance. |