INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 30, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment and Healing 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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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ensure that there was ventilation in the first-floor bathroom by fan or window. It was observed that the fan was inoperable.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility failed to ensure that there was ventilation in the first-floor bathroom by fan or window as the fan was inoperable.
The Facility Director has contacted the landlord to address the issue of the non working ventilation fan in the first floor bathroom.
The agency will be in compliance with this standard as of 10/31/2021. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the policy and procedures manual and client rights documentation on September 30, 2021, the project failed to include all parts of the client rights regulation. The project failed to include that a client may not be discriminated against creed, sex, color, and national origin in seven out of seven records.
This is a repeat citation from the September 24, 2020 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
the project failed to include all parts of the client rights regulation. The project failed to include that a client may not be discriminated against creed, sex, color, and national origin in seven out of seven records.
The program director will review and correct the client rights policy in the policy and procedure manual and client rights documentation to ensure that it includes that a client may not be discriminated against creed, sex, color, and national origin. This policy and documentation change will be reviewed with all facility directors and counselors and each client will receive an updated version of the client rights documentation so that all have been updated about the client rights regulation.
The agency will be in compliance with this standard on 10/31/2021 |