INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 8-9, 2013 staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Conewago Snyder 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observations during the physical plant inspection, the facility failed to ensure that there were no heaters that were not permanently mounted or installed within the facility.
The findings include:
The physical plant inspection was conducted with the Facility Director on August 8, 2013. The Licensing Specialist observed a portable heater in a counselor office. The extension for that office was x2908.
The Facility Director confirmed the findings.
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Plan of Correction
The space heater found in office x2908 was removed from the facility and all staff were retrained on DOH Physical Plant Standard #705.8(2) on August 9, 2013 by the Facility Director.
The Facility Director will monitor for ongoing compliance during daily facility walk-throughs (physical plant inspections). |
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.
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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 August 8, 2013. 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, July 2012 to August 2013. During that time frame, the facility documented fire drills during sleeping hours on 7/8/12 and 3/31/13, which is eight months apart.
The Facility Director confirmed the findings.
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Plan of Correction
Corporate Compliance Officer reviewed Firetree Policy #2-040 Fire Prevention / Protection / Safety and Emergency Evacuation Plans which pertains to fire drill procedures with the Facility Director on August 9, 2013 to ensure her understanding.
The Facility Director will ensure that a fire drill is conducted and documented during client sleeping hours each quarter as per facility policy.
Corporate compliance officer will monitor ongoing compliance during internal audits on a monthly basis. |
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 inform the client, in writing, of a decision to involuntarily terminate the client's treatment in two of two client records.
The findings include:
Two client records which required documentation of written notification to the client informing him/her of the decision to terminate the client's treatment were reviewed on August 8-9, 2013. The facility failed to document notification to the client in records #18 and 19.
Client # 18 was admitted on 5/28/13 and discharged on 7/8/13 due to non-compliance with treatment. This client record did not include documentation from the facility of the written notification to terminate this client's treatment at the project.
Client # 19 was admitted on 4/16/13 and discharged on 6/20/13 due to non-compliance with treatment. This client record did not include documentation from the facility of the written notification to terminate this client's treatment at the project.
The Compliance Officer and Facility Director confirmed the findings.
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Plan of Correction
The primary counselor will complete a Notice of Termination Report for files #18 and #19 in the client's electronic file and forward a copy to the client on August 30, 2013.
The Facility Director will retrain all facility clinical staff on the appropriate completion of involuntary termination reports during the clinical meeting on August 30, 2013.
The Corporate Compliance Officer will monitor ongoing compliance during internal audits on a monthly basis. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to document a discharge summary in two of five client records.
The findings include:
Five client records which required documentation of a discharge summary were reviewed on August 8-9, 2013. The facility failed to document a discharge summary in client records # 17 and 19.
Client # 17 was admitted on 5/16/13 and discharged on 6/13/13. This client record did not contain a discharge summary as of the date of the inspection.
Client # 19 was admitted on 4/16/13 and discharged on 6/20/13. This client record did not contain a discharge summary as of the date of the inspection.
The Compliance Officer and Facility Director confirmed the findings.
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Plan of Correction
The primary counselor will complete a discharge summary report for files #17 and #19 in client's electronic file.
The Facility Director will retrain all facility clinical staff on the appropriate completion of discharge summary reports during the clinical meeting on August 30, 2013.
The Corporate Compliance Officer will monitor ongoing compliance during internal audits on a monthly basis. |