INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, SPHS Behavioral Health - Latrobe 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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705.24 (1) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(1) Provide bathrooms to accommodate staff, clients and other users of the facility.
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Observations
Based on a physical plant inspection, the facility failed to have hot and cold water under pressure.
The findings include:
A physical plant inspection was conducted on January 21, 2015 at approximately 10:00 AM. At the time of the inspection, there was no hot water in any of the bathrooms or staff kitchen within the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The landlord will be notified that the hot water is not working and will be fixed by 1/22/2015. The Supervisor will continue to monitor the temperature. |
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 fire drill logs, the facility failed to document unannounced fire drills at least once a month.
The findings include:
The fire drill logs were reviewed on January 21, 2015. There were no fire drills conducted between the months of November 2013 to November 2014.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will review with the Clinical supervisor the policy and procedure for conducting fire drills. Random unannounced fire drills will occur monthly and will be documented in the fire drill log. This will be completed by 1/21/2015. Clinical supervisor will follow up and review documentation of fire drills. |
709.93(a) LICENSURE Client records
709.93. 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:
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Observations
Based on a review of client records, the facility failed to document a complete client record which included case consultations and/or follow ups in seven of ten client records.
The findings include:
Ten client records were reviewed on January 21, 2015. All ten records required a case consultation and/or follow up. Client records #1, 3, 6, 7, 8, 9 and 10 did not have documentation of a case consultation and/or follow up.
Client #1 was admitted on May 5, 2014. Case consultations were documented on July 30 and December 29, 2014. There was no case consultations documented during the third quarter (September - November 2014).
Client #3 was admitted on September 22, 2014. There were no case consultations documented in client record #2.
Client #6 was admitted on January 22, 2014 and discharged May 14, 2014. There were no case consultations documented in client record #6.
Client #7 was admitted on January 27, 2014 and discharged June 24, 2014. There were no case consultations and no follow up documented in client record #7.
Client #8 was admitted on January 29, 2014 and discharged June 9, 2014. There were no case consultations and no follow up documented in client record #8.
Client #9 was admitted on February 25, 2014 and discharged June 25, 2014. There was no follow up documented in client record #9.
Client #10 was admitted on January 8, 2014 and discharged June 9, 2014. There was no follow up documented in client record #10.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A mandatory staff meeting will be held with all staff to review case consultation and follow up timelines and regulations by the clinical supervisor. This will occur no later than Feb 15, 2014. Each staff member will be provided with a copy of our agency's policy and regulations in regard to case consultation timelines and follow up process. In addition, staff members who were responsible for charts 1, 3, 6, 7, 8, 9, and 10 will correct these deficiencies no later than February 15, 2015. To assure staff members are improving in this area internal chart reviews and supervision will take place by the Clinical Supervisor. |