INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on 03/15/2016, and 03/16/2016, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Home Nursing Agency Community Services 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
|
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on an inspection of the physical conducted on 03/16/2016, the facility failed to ensure that the hot water temperature in the facility bathrooms did not exceed 120 degrees Fahrenheit. The findings include:The temperature for the hot water in the men's bathroom located next to the vending machine's in the group counseling rooms area was tested at 127.0 degrees Fahrenheit. The temperature for the hot water in the women's bathroom located next to the vending machine's in the group counseling rooms area was tested at 129.0 degrees Fahrenheit.The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The water temperature has been turned down at the hot water tank source area to 120 degrees Fahrenheit.
A weekly check of the temperature in the identified bathrooms will be completed and a log of the temperature will be maintained weekly for 4 months beginning May 2, 2016. This will be completed by the facility's security guard or his supervisor, Administrative Support Manager. This weekly checking and documenting will occur for May, June, July and August 2016.
Beginning in September 2016, we will complete monthly water temperature checks and document this on a log. This monthly check and log will be kept indefinitely to ensure the water temperature does not exceed 120 degrees Fahrenheit. Again, the checking of the water temperature and the documentation will be completed by the facility's security guard or his supervisor, Administrative Support Manager.
These temperature logs will be available for DDAP review. |
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.
|
Observations
Based on a review of client records, the facility failed to ensure that client treatment plan updates were performed every 60 days.The findings include:Ten client records requiring documented treatment plan updates every 60 days were reviewed. Three of the ten records reviewed did not have documented treatment plan updates performed at least every 60 days.Client #1 was admitted for treatment on 10/25/2015, and was discharged on 01/28/2016. The client's individualized treatment plan was completed on 11/05/2015, but the client's treatment plan update was dated 1/07/2016. Client #3 was admitted for treatment on 10/28/2015, and was an active client at the time of the onsite inspection. The client's individualized treatment plan was completed on 11/05/2015, but the client's treatment plan update was dated 1/07/2016. Client #8 was admitted for treatment on 6/25/2015, and was an active client at the time of the onsite inspection. The client's individualized treatment plan was completed on 6/30/2015, but the client's treatment plan update was dated 10/07/2015.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Monthly random chart audits are being completed on D&A services by the D&A program supervisor. This was started in January and timely treatment plan completion and timely treatment plan updates are a part of this review. The supervisor is in these charts regularly looking for plans that are due for update. The data from these chart reviews is transferred into a Performance Improvement Matrix form to identify any areas which are not meeting standards. The program supervisor will continue there chart reviews with a focus on treatment plans and updates.
Weekly staff meetings are held with D&A counselors to review caseloads and pending documentation that will need to be completed - treatment plans and treatment plan updates are a part of this discussion.
|