INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 23, 2010 through June 24, 2010 licensure renewal inspection. The follow-up inspection was conducted on January 11, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, RHD New Start II 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 and a plan of correction is due on February 6, 2011.
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Plan of Correction
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the tour of the physical plant, the facility exceeded the water temperature past 120 F.
The findings include:
The water temperature was tested on January 11, 2011 at around 4:00 pm. The first floor client restrooms water tested over 120 F, at 139 F which exceed the required temperature. The maintenance supervisor and clinical supervisor confirmed that it exceeded the required temperature of 120 F during the follow-up inspection.
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Plan of Correction
The water temperature exceeded the 120F temperature. The residential supervisor adjusted the temperature to read 117F. The facility director reviewed the weekly log and found the the temperature fluctuated. The residential supervisor contacted a plumber to research a way ensure a constant temperature regulation. The residential supervisor will continue to take weekly temperture readings on all floors and make adjustments as needed to ensure compliance.The Director will review the logs monthly. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on the review of the fire drill record, the facility failed to ensure that fire drills are conducted on different times of the day.
The findings include:
The fire drill record was reviewed on January 11, 2011. There were no documentation of a drill conducted on the overnight shift. All drills were conducted on either the morning, afternoon or evening. The following months were reviewed July, 2010, August 2010, September 2010, October 2010, November 2010, December 2010 and January 2011. This was confirmed by the clinical supervisor during the follow-up inspection.
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Plan of Correction
The Facility Director and Residential Supervisor met to review the fire drill system and drafted a yearly schedule of dates and times of required drills to ensure that the fire drills are conducted at different times of the day, evening and overnight. In addition to the scheduled drills, random drills will occur as well. The residential team leaders will conduct the drills and submit the record to the Residential Supervisor for review. The facility director will review the logs quarterly to ensure compliance. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Due to the fact that this cannot be re-evaluated until the next licensing inspection please resubmit the original plan of correction.
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Plan of Correction
The corporate office did publish the annual audit within the prescribed timeframe outlined in the policy and procedure manual. However, in order to comply with the standard the RHD central office management will ensure that the annual audit is completed and made available by December 30 of each year. In addition, they will apply for an exception to ensure that they are in compliance if they cannot meet the timeframe as outlined. The audit will be made available by 12/30/2011. |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
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Observations
Based on the review of the medication record and an interview with the facility director, the facility failed to document medication inventories
The findings include:
The medication record was reviewed on January 11, 2011. Per the facility policy and procedure, medications will be inventoried monthly by the residential counselor. During the review of the medication records there was no documentation of inventories being conducted. An interview was conducted with the clinical supervisor and she confirmed it was not done.
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Plan of Correction
The facility director failed to ensure that the inventories were conducted monthly as outlined in the policy and procedure manual. The facility director will that the Residential Supervisor conducts an inventory on later than the first day of the month for the previous month's medications. The count will be forwarded to the facility direcotr for review. The facility will begin inventories and be in compliance by 3/1/2011 and every month thereafter. |
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 complete psychosocial evaluations in three of eight client records reviewed.
The finding includes:
Eight records were reviewed on January 11, 2011. Psychosocial evaluations were required in four records reviewed. Per the facility's policy and procedure manual psychosocial evaluations are to be completed within 30 days of the clients admissions date.
Client records # 1 failed to document the client's problems and needs, coping mechanisms, negative factors that might inhibit treatment and the counselor conclusions/impressions.
Client records #2 was admitted on November 18, 2010 and their psychosocial evaluations was to be completed by December 18, 2010. As of to date of the follow-up inspection, there was no documentation of the client's psychosocial evaluations.
Client records #4 was admitted on September 30, 2010 and their psychosocial evaluations was to be completed by October 30, 2010. As of to date of the follow-up inspection, there was documentation of the client's psychosocial evaluations, but the date the psychosocial evaluation was not documented and could not assume it was completed within the 30 days of the clients admission..
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Plan of Correction
After reviewing record #1 and record #2 The facility Director and clinical supervisor met with the assigned therapist and discussed completing work within the required time frames and documenting all the areas needed. The therapist was given a verbal warning and instructed that we would be using progressive discipline to ensure future compliance. The facility director and the clinical supervisor reviewed record # 4 and met with assigned therapist and discussed the expected timeframes. The therapist was informed that going forward progressive discipline would be used to ensure compliance with the documentation standards. Both therapists put the completed forms in the file on 1/13/2011. The clinical supervisor will review random records weekly to ensure compliance. All active records will be in compliance 2/28/2011.
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