INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18, 2014, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Laure Rohrs Gargano 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 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential 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 the review of administrative documentation, the facility failed to provide a certificate of occupancy from the Department of Labor and Industry or its local equivalent.
The findings include:
Administrative documentation was reviewed on June 8, 2014. The Facility Director failed to provide a copy of the Certificate of Occupancy from the Department of Labor and Industry or its local equivalent.
The Facility Director confirmed this finding.
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Plan of Correction
The facility director has requested the Occupancy Certificate from the property owner. The department of Labor and Industry in Harrisburg, Pa forwarded the approved building plans rather than the Occupancy Certificate. The property owner is actively seeking the correct paper work from DL&I , he anticipates he will have the certificate by end of August to mid September based in the six week turn around to receive the incorrect paper work. Once this is received the copy will be forwarded the DDAP Licensure |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant inspection, the facility failed to maintain a minimum of two exits on every floor, that are separated by a minimum distance of 15 feet.
The findings include:
A physical plant inspection was conducted on June 18, 2014 at approximately 9:30 am. The facility failed to maintain a minimum of two exits on every floor as the only means of egress was the front entrance door.
The Facility Director confirmed these findings.
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Plan of Correction
Based on the square footage of the office space, a second exit is not required by code and the space is approved by the DL&I via an occupancy certificate. The facility does not provide group therapy, nor intends to include group therapy at the location. The services are individual/family therapy only. The greatest number of people in the space at any given time will not exceed 6 between the two available counseling office spaces.
In the event of emergency and the door exit from the office space is blocked or obstructed; both counseling office spaces have windows where the sills are:
26" off the floor, the opening of the window is 20" and the height of window opening is 48". These measurements are within code to use the window as an emergency exit.
The facility director will place an emergency exit sign at the window and include this exit choice on the diagram in the room to guide people toward exits. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or a fire extinguisher company.
The findings:
A physical plant inspection was conducted on June 18, 2014 at approximately 9:30 am. The facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating. The fire extinguisher located next to the entrance was not up to date with its inspection; it was last inspected by Susquehanna Fire Equipment Company in May of 2013.
The Facility Director confirmed this finding.
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Plan of Correction
The facility director had the expired fire extinguisher replaced by the property owner with a currently inspected ABC rated fire extinguisher - inspected May 2014.
7/25/14:
The facility director brought the issue to the property owner. The property owner has taken the following steps to ensure the extinguishers remain current by: contracting with an outside service provider to inspect all fire extinguishers on an annual basis. The provider is scheduled to inspect all fire extinguishers on the premises annually occurring in May each year. |
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 complete psychosocial evaluation in ten out of ten records.
The findings include:
Ten client records were reviewed on June 18, 2014. A psychosocial evaluation was required in all ten records.
Client record #8 lacked an assessment of the client's presenting issue(s).
Client records #2 and 8 lacked an assessment of the client's perception / readiness for treatment.
Client records #1, 2, and 3 lacked an assessment of the client's assets/strengths.
Client record #8 lacked an assessment of the client's mental status.
Client records #1, 2 and 3 lacked an assessment of the client's support systems.
Client records #1 and 2 lacked an assessment of the client's coping mechanisms and how they would relate to or impact treatment.
Client records #1, 2, 3, 4, 5, 6, 7, 8, 9 and 10 lacked an evaluative statement and/or recommendation based on the information gathered from client risk histories.
The Facility Director confirmed these findings.
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Plan of Correction
The facility director will reformat the psychosocial summary headings to explicitly outline required content.
7/25/14:
changed due date to July 31, 2014 |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to complete preliminary treatment and rehabilitation plans in nine of ten client records.
The findings include:
Ten client records were reviewed on June 18, 2014. All ten client records required the completion of preliminary treatment and rehabilitation plan. Preliminary treatment and rehabilitation plans were not completed in client records #1, 2, 3, 4, 5, 6, 8, 9, and 10.
Client # 1 was admitted on October 16, 2013 and discharged on April 30, 2014. The preliminary treatment and rehabilitation plan was not completed.
Client # 2 was admitted on November 18, 2013 and discharged on May 24, 2014. The preliminary treatment and rehabilitation plan was not completed.
Client # 3 was admitted on February 22, 2013 and discharged on April 30, 2014. The preliminary treatment and rehabilitation plan was not completed.
Client # 4 was admitted on March 2, 2013 and discharged on February 7, 2014. The preliminary treatment and rehabilitation plan was not completed.
Client # 5 was admitted on June 27, 2013 and discharged on February 19, 2014. The preliminary treatment and rehabilitation plan was not completed.
Client # 6 was admitted on July 2, 2013 and discharged on January 24, 2014. The preliminary treatment and rehabilitation plan was not completed.
Client # 8 was admitted on October 24, 2013 and was still an active client at the time of this inspection. The preliminary treatment and rehabilitation plan was not completed.
Client # 9 was admitted on June 29, 2013 and was still an active client at the time of this inspection. The preliminary treatment and rehabilitation plan was not completed.
Client #10 was admitted on July 5, 2013 and was still an active client at the time of this inspection. The preliminary treatment and rehabilitation plan was not completed.
The Facility Director confirmed these findings.
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Plan of Correction
The facility director will include a standardized preliminary treatment plan with items to be selected based on client scenario - this will be added the initial packet of paper work reviewed with each client for signatures ie: ROI's, consent treatment.
7/25/14:
Changed corrective action date to July 31, 2014 |
709.93(a) LICENSURE Client records
709.93. 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:
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Observations
Based on a review of client records, the facility failed to provide a complete client record to include consent forms, medication records, record of services provided, referral contact, progress notes, individualized treatment plan, client-related correspondence, case consults, aftercare plan, discharge summary, and follow-up information in three of ten client records.
The findings include:
Ten client records were reviewed on June 18, 2014. The facility failed to provide a complete client record for clients #3, 5, and 7.
Client # 3 was admitted on February 22, 2013 and discharged on April 30, 2014. There was no documentation of an aftercare plan.
Client # 5 was admitted on June 27, 2013 and discharged on February 19, 2014. There was no documentation of an aftercare plan.
Client # 7 was admitted on April 9, 2013 and was still an active client at the time of this inspection. There was no documentation of an individual treatment and rehabilitation plan.
The Facility Director confirmed these findings.
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Plan of Correction
The facility director will have clinicians begin and complete the review of after care planning earlier in the discharge process rather than waiting until the final session. The aftercare plans will be completed within the two session prior to the final sessions prior to final meeting with the client.
Client #7 The treatment plan was outdated, and the 60 day updates reflected progress/lack of progress and new goals to address in treatment. This in hindsight, lacks verification that new/additional/extended goals had been reviewed with client.
The facility director will have and new/additional/extended treatment goals identified in the treatment plan update transcribed onto the approved comprehensive treatment plan form to reflect review/signature of the client.
7/25/14: Changed corrective action date to July 31, 2014 |