INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 5, 2017 through December 6, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Crisis Management Services, 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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705.2 (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 conducted on December 6, 2017 at approximately 10:30 am, it was observed that the facility failed to store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents as the dumpster, which is located outside in the parking lot, was missing one of the two lids.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The trash removal service utilized by Crisis Management Services (Gold Medal Environmental Services) will install a new trash dumpster by January 15, 2018
The Director of Maintenance will insure that the new trash dumpster is installed by January 15, 2018.
The Project Director will inspect the trash store area on a weekly basis to insure that trash is being stored in an appropriate fashion and that the dumpster is intact and in working order |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on December 6, 2017 at approximately 2:30 pm, the hot water temperature in the client and staff bathrooms the facility was measured at 123.3 degrees Fahrenheit. Additionally, the exhaust fan, located in the bathroom in room 163, was inoperable and the bathroom did not have a window to allow proper ventilation.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1) Our maintenance department has already corrected the water temperature problem at the facility.
As part of the ongoing preventive maintenance plan, they will check on the water temperature at the facility to ensure that the hot water remains at 120 degrees or less.
2) the exhaust fan in room 163 has been repaired and is now fully operational. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the fire drill logs from December 2016 to October 2017, the facility failed to prepare alternate exit routes to be used during fire drills as the east exit was the exit route used during every fire drill that took place during the reviewed timeframe.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drills scheduled throughout the year will alternate between using the east and the west exit from the facility.
The Project Director, Director of Maintenance, Security Director and relevant program staff will meet to review the specifics by utilizing both program exits during fire drills.
Substance Abuse Technicians will utilize a portion of the consumer's empowerment meeting on a weekly basis to educate consumers on utilizing both the East and West exits during a fire drill.
The Project Director will review the results of each fire drill to determine that both exist are used during fire drills.
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on the review of 7 client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in 2 client records. Additionally, 2 client records reviewed had consent to release information forms that were missing required elements.
Client #2 was admitted on 10/8/17 and was an active client at the time of the inspection. There were two consent to release information forms, one to a family member and one to a significant other, both signed and dated by the client on 10/17/17; however, neither consent form included the purpose for the disclosure.
Client #3 was admitted on 11/8/17 and was an active client at the time of the inspection. There was a consultation with an outside medical provider, dated 11/24/17, that identified the facility as the requesting agency and listed the client's name; however, there was no consent to release information form on file prior to the disclosure. Additionally, there was a consent to release information form, signed and dated by the client on 11/15/17, to a family member; however, the consent form did not include the purpose for the disclosure.
Client #4 was admitted on 9/26/17 and was discharged on 10/20/17. There was a consultation with a physician, dated 11/24/17, that identified the facility as the requesting agency and listed the client's name; however, there was no consent to release information form on file prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory staff training will be held in mid January to cover all aspects of client confidentiality and the regulations governing release of information.
A review of the river's bend release of information form will also be conducted and examples of the proper use of each item on the form will be provided.
The staff training will be conducted by the Project Director.
The Project Director will conduct an unannounced chart review on a monthly basis. The focus of the review will be on assessing if release of information forms have been filled out accurately and completely.
The consumers whose records were cited met with the program nurse and/or individual therapist who reviewed the specific release of information form that was cited and explained to them the corrections.
All active charts were corrected within 24 hours.
all corrections were reviewed by the project director. |