INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on February 7 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Adapt House 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 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on observation during a physical plant inspection, the facility failed to store trash in covered containers with lids.
The findings include;
A physical plane tour was conducted on February 7, 2012. The facility failed to store all trash, garbage and rubbish with a covered lid. Two dumpsters located outside of the main building failed to have the lid closings on top of the trash.
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Plan of Correction
The Maintenance Supervisor will post a
"Lids Must Be Closed At All Times" sign on the dumpsters. The Maintenance Supervisor/or designee will also do a visual check at least twice a day to ensure that the lids are closed. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to provide a means of drying ones hands located a facility bathroom.
The findings include:
A physical plant inspection was completed on February 7, 2012. The mechanical dryer in the men's bathroom failed to work and paper towels were not available at the time of the physical plant inspection.
The project director and physical plant manager confirmed the mechanical dryer was not working in the men's bathroom.
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Plan of Correction
The maintenance supervisor has placed an order for a mechanical dryer to replace the broken one in the men's bathroom located in the D&A facility (208-216 Madison Avenue).
Individual paper towels have been placed in the bathroom and will be available for use until the new dryer is received and put in place.
The Maintenance Supervisor/designee shall check the bathroom on a daily basis to ensure that paper towels are in place and available for use. |
709.26(a)(10) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(10) Work performance evaluations.
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Observations
Based on a review of the agency policy and procedure manual and personnel records, the facility failed to document annual work performance evaluations in adherence to agency policy.
The findings included;
During the review of personnel records on February 7, 2012, the facility failed to have an annual performance evaluation documented in compliance with written agency policy.
Employee # 5 was hired 8-07-09. The last annual performance evaluation was completed in August 2010. No documentation of a written performance was documented for 2011.
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Plan of Correction
An annual performance evaluation has been completed for employee #5.
The Facility Director has put into place and shall ensure, by a system of monthly checks, that all annual work performance evaluations are completed and documented during the appropriate time frame. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. 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 document a new psychosocial evaluation upon a re-admit to the program in one of eight records.
The findings include:
Eight client records were reviewed on February 7, 2012. The facility failed to document a new psychosocial evaluation in record # 1, following readmission to the facility. The first psychosocial was completed on 6-14-2011. The client was discharged and later re-admitted on 1-12-2012. The psychosocial evaluation was updated, however the first one was completed 7 months prior to the update and a new psychosocial should have been completed.
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Plan of Correction
1.For all clients being admitted, the Clinical Supervisor will determine the date of the bio-psychosocial evaluation (BPS)that was completed during the most recent prior admission.
2.When the BPS due date of the current admission is 6 moths or less from the completion date of the BPS that was completed during the most recent admission:
a. The Clinical Supervisor will obtain a copy of the prior BPS from the file from the file for the client's previous admission.
b. A counselor/counselor assistant will update the prior BPS and complete a new BPS summary.
3. When the BPS due date of the current admission is more than 6 months after the completion date of the BPS that was completed during the most recent prior admission, a new BPS will be completed.
4. To ensure that no prior BPS will be updated if it is more than 6 months old, the clinical supervisor alone will have access to the closed files and will not make available to counselor/counselor assistants any BPS that is more the 6 months old.
5. The clinical supervisor will inform all counselors/counselor assistants of this citation, explain the reason for it and explain the plan of correction. |