INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. Pine Ridge 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record including the exit route used.
The findings include:
Fire drill records for October 2013 through August 2014 were reviewed on September 12, 2014. The facility failed to document the exit route utilized during the following fire drills: 10/7/13, 11/9/13, 12/22/13, 1/23/14, 2/18/14, 3/21/14, 4/23/14, 5/18/14, 6/17/14 and 7/17/14.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director, BH Tech Supervisor, and Risk Committee Members developed a new written fire drill record to include date, time, the amount of time it took for evacuation, the exit route utilized, the number of persons in the facility at the time of the drill, problems encountered during the drill, and whether the fire alarm or smoke detector was operative.
The BH TEch Supervisor will review fire drill log monthly, to ensure that each drill is being performed and documented correctly. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two of three client records.
The findings include:
Nine client records were reviewed on September 12, 2014. Three records pertained to clients that were involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in client records # 6 and 7.
Client # 6 was admitted into treatment on March 31, 2014 and was involuntarily terminated from treatment at the project on April 22, 2014. Client record # 6 did not include written notification of the decision to involuntarily terminate the client's treatment at the project as of September 12, 2014.
Client # 7 was admitted into treatment on February 28, 2014 and was involuntarily terminated from treatment at the project on March 20, 2014. Client record # 7 did not include written notification of the decision to involuntarily terminate the client's treatment at the project as of September 12, 2014.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director, Lead Counselors, and Counselors reviewed the Involuntary Termination Letter for clients being involuntarily discharged from the program. All clinical staff will utilize this form for all involuntariy discharges. Staff will meet with the client upon discharge and provide them with a written letter, describing the reason for their involuntary termination from the program.
The Program Director and Lead Counselor will review all discharge charts to ensure that these are being provided to the client upon their discharge. In the event that a client refuses a copy, clinical staff will mail a copy to the client at their forwarding address. |