INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on July 25, 2013, by staff from the Program Licensure Division. Based on the findings of the on-site complaint investigation, Treatment Trends, Inc. Keenan 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 a physical plant inspection, the facility failed to 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.
The findings include:
A complaint investigation was completed at the facility on July 25, 2013. Upon leaving the facility, it was discovered that the dumpsters located next to the building were unable to be closed as they were overflowing with garbage.
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Plan of Correction
Keenan House has ordered an additional garbage container from our contracted trash collector. I have been informed that the expected delivery date is September 15, 2013. This additional container should meet our needs and satisfy standard 705.2 which addresses "Building Exterior and Grounds. Daily house checks conducted by clinical technicans will be expanded to include trach and recycling containers. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the communications log, facility policy and procedures, and interviews with the facility director and a staff person, the facility failed to develop and follow policies and procedures to address illicit substance use on premises.
The findings include:
During a complaint investigation on July 25, 2013, it was determined that there were illicit substances being brought in and used on the premises prior to the date of this investigation.
The Facility Director confirmed the findings.
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Plan of Correction
Keenan House staff and administration responded quickly and responsibly to the occurance of illicit substances entering the facility.
A new policy was developed by the Clinical Director on July 30, 2013 in collaboration with law enforcement and Quality Assurance to ensure proceedures are clear. Standard 709.24(a)(3), "Treatment/Rehabilitaion Management" is addressed with the addition of Keenan House policy and proceedure 10.2 "Illicit Substance Use on Premises."
The Program Director is responsible to ensure that the cor5rective action is followed. Training will occur for all staff responsible for searches of property and person within the facility. This training, conducted by the Clinical Director and the Vocational Director, will take place by August 29, 2013. |