INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, SPHS Behavioral Health 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
The facility failed to ensure privacy so counseling sessions cannot be seen or heard outside the counseling room.
A physical plant inspection was conducted on February 14, 2020. At the time of the physical plant inspection, the licensing specialist could hear the counseling session that was taking place while standing in the office for clerical staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Director contacted all Program Supervisors in Westmoreland and Fayette County locations. Program Supervisors were polled on the number of sound machines needed to fully preserve the confidentiality of individual and group therapy sessions at their facilities. All Program Supervisors reported back with numbers accounting for extra machines in the event of future machine failures. Clinical Director and Administrative Assistant submitted a purchase order for a bulk order of 36 total sound machines. Clinical Director picked up the order and delivered all sound machines to respective Outpatient locations by 2/27/2020. All sound machines were installed around the office to further secure confidentiality of all counseling sessions. |
705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
The facility failed to maintain protective caps over each electrical outlet.
A physical plant inspection was conducted on February 14, 2020. At the time of the physical plant inspection, there were three outlets located in the child's play area, off of the waiting room, that did not have caps/covers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Supervisors were informed by Program Director to purchase protective covers for electrical outlets. Protective covers were purchased by Program Supervisors and were inserted at facility locations by 2/27/2020. The finding has been added to SPHS' internal mock audit checklist for ongoing examination. |