INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 26 -27, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Pyramid Healthcare Inc. - Transitions 2 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:
|
Plan of Correction
|
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
Fire drill logs were reviewed on October 26, 2011. Documentation of a fire drill conducted during sleeping hours is required once every six months. The fire drill logs were reviewed from the last survey, October 2010 to September 2011. During that time frame, the facility documented only one fire drill during sleeping hours which was February 23, 2011 at 5:00 am.
This was discussed with and confirmed by the facility director on 10-26-2011.
|
Plan of Correction
Maintenance to ensure that fire drills are conducted during sleeping hours at a minimum of every 6 months. Director of Pysical Plants to oversee that process. Reports to be reviewed at monthly facility risk meeting. |
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.
|
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 one of one client records.
The findings include:
Eleven client records were reviewed on October 26-27, 2011. One client record was required to notify the client, in writing, of a decision to involuntarily terminate the client's 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 record # 2.
Client # 2 was admitted into treatment on August 18, 2011 and was involuntarily terminated from the project on September 8, 2011. There was no documentation of written notification of termination to the client, at the time of the licensing inspection, on October 26-27, 2011.
The facility director and the clinical supervisor confirmed that an involuntary termination notice was not included in client record #2.
|
Plan of Correction
Program Director will conduct a training regarding termination policy and necessary forms with all staff prior to January 1, 2011. Clinical Supervisor will monitor completion of from through the use of Chart monitors monthly until 100% completion is achieved. |