INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Creative Health Services Inc. 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill log, the facility failed to conduct unannounced fire drills at least once a month.The findings include:On April 8, 2013, the facility's fire drill log was reviewed covering the period of May 2012 through March 2013. The facility failed to conduct unannounced fire drills during two out of ten months, specifically, February 2013 and March 2013 .The Facility Director confirmed the findings.
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Plan of Correction
By 05/01/13 the facility director in conjunction with the Chief Operating officer will ensure that unannounced fire drills will be conducted and recorded one time per month. The facility director and the chief operating officer will be responsible in ensuring that the unannounced fire drills are performed monthly. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 the facility's fire drill log, the facility failed to maintain a written fire drill record including the number of persons in the facility at the time of the drill. The findings include:On April 8, 2013, the facility's fire drill log was reviewed covering the period of May 2012 through March 2013. The facility provided a Fire Drill Record that did not include the number of persons in the facility at the time of the drill.The Facility Director confirmed the findings.
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Plan of Correction
By 05/01/13 The facility Director will develp and utilize a fire drill log which will include the date, time, the amount of time it took for evacuation the exit route used the number of individuals in the facility at the time of the drill, problems encountered and wheteher the fire alarm was operative. The log will include an area to provide space, to indicate the number of persons in the facility at the time of the drill. First and last initials will be documented to verify number of persons included in the fire drill. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility's fire drill log, the facility failed to alternate exits during fire drills.The findings include:On April 8, 2013, the facility's fire drill log was reviewed covering the period of May 2012 through March 2013. The facility failed to alternate exits during eight out of eight fire drills conducted.The facility documented on each fire drill record under exit route used, "D/A OP Door."The Facility Director confirmed the findings.
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Plan of Correction
By 05/01/2013 facility director will have a staff meeting with all staff, to discuss the need for use of alternate exits to use during a fire drill. The facility director will educate all staff on the use of other dorrs and the need to use alternate doors during a fire drill. Facility director will record and document the use of the alternate exits in the fire drill log as well as identify where these exits are located. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of administrative documentation, the governing body failed to make available to the public an annual report.The findings include:The facility's administrative documentation was reviewed on April 8 - 9, 2013. The governing body was required to make the 2012 annual report available to the public. The facility failed to make annual report available to the public.The 2012 annual report was provided during the inspection; however, the governing body failed to review and approve the report; in addition, the report did not include a statement disclosing the names of officers, directors and principal shareholders. During the inspection and exit interview the Facility Director and Chief Operating Officer confirmed that the governing body did not review or approve the 2012 annual report; therefore, the annual report could not be made available to the public.
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Plan of Correction
The governing body will publish and make public the 2012 annual report on 05/21/13 at a regularly scheduled board meeting. The 2012 report includes a statement of officers, directors and principal shareholders. Moving forward the facility director will ensure that the statement of officers, directors and principal shareholders will be included in the annual report. The project director and facility director will review said document to ensure compliance. The facility will ensure that the annual report is made public by the end of the fiscal year. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records and a review of the facility's policy and procedures manual, the facility failed to document a treatment plan update which included an assessment of progress in three of five records reviewed.The findings include:The facility policy states: " The process of the treatment plan review is critical to providing continuous treatment that is appropriate for the client's identified problems and their stage of change. It is a process that requires a thorough review of the client's recovery efforts, physical health, mental health, stage of acceptance, recovery supports and movement toward positive resolutions. The process of the review requires the therapist to look objectively at the client's behavior that would either indicate movement toward problem resolution or away from problem resolution. The primary purpose of the treatment plan review and update is to review and evaluate the client's progress."Five client records requiring documentation of an assessment of progress on treatment plan updates were reviewed on April 9, 2013. The facility failed to document an assessment of progress on treatment plan updates in three of five records reviewed; in particular client record # 1, 3, and 5.Client # 1 was admitted to the program on 10/25/12. The individual treatment plan was documented on 10/25/12. The facility documented two treatment plan updates on 12/10/13 and 2/14/13; however the updates did not include the client's progress in relationship to the stated goals of the comprehensive treatment plan.Client # 3 was admitted to the program on 11/14/12. The individual treatment plan was documented on 11/27/12. The facility documented two treatment plan updates on 1/15/13 and 3/22/13; however the updates did not include the client's progress in relationship to the stated goals of the comprehensive treatment plan.Client # 5 was admitted to the program on 1/16/13. The individual treatment plan was documented on 1/16/13. The facility documented a treatment plan updated on 3/16/13; however the update did not include the client's progress in relationship to the stated goals of the comprehensive treatment plan.The Facility Director did not dispute the findings.
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Plan of Correction
BY 05/08/2013 Facility Director /Clinical Supervisor( #2) will orient clinical staff to DOH client record standards, and will review client record #1, #3, and #5 (Treatment Plan updates) during individual clinical supervision. Director/ Clinical Supervisor (#2)has reviewed charts of client #1, client #3,and client #5 and has addressed these treatment plan updates in a staff multidisciplinary team meeting. The staff were educated on understanding the necessity in including the clents progess in relationship to the stated goal as a means for a comprehensive treatment plan. The facility Director will review facility policy and procedure manual,with all staff, to ensure compliace of record keeping standards. |