INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 16, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Treatment Access and Services Center of Berks County, Inc. (TASC) was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
|
Observations
Based on a review of the physical plant, the facility failed to ensure that the bathrooms were properly ventilated by an exhaust fan or window.
The findings include:
A physical plant inspection was conducted on March 16, 2016. The facility failed to ensure that the bathrooms were properly ventilated by an exhaust fan or window as the exhaust fans in two of the four bathrooms being use by staff, client , and visitors did not work.
The ventilation fan in the women's staff bathroom on the second floor did not work. The ventilation fan in the client and visitors bathroom on the second floor did not work.
These finding were reviewed with facility staff during the licensing process
|
Plan of Correction
On 3/24/16, the maintenance staff from Service Access Management (SAM), Inc. repaired the exhaust fans in both bathrooms in question. Both fans are now working properly. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Base on a review of the physical plant, the facility fail to ensure that the fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection is to be indicated on the extinguisher or inspection tag.
The finding include:
A physical plant inspection was conducted on March 16, 2016. The facility fail to ensure that the fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company as the fire extinguisher on the south end of the second floor was last inspected in February of 2015. The fire extinguisher was to be inspected February of 2016.
These finding were reviewed with facility staff during the licensing process
|
Plan of Correction
On 3/25/16, the maintenance staff from Service Access Management (SAM), Inc., from whom TASC leases its office space, verified that the fire extinguisher in question has been officially inspected for 2016. |
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.
|
Observations
Based on a review of fire drill records, the facility failed to conduct an unannounced fire drill at least once a month.
The findings include:
A review of the facility's fire drill records was conducted on March 16, 2016. There was no documentation of an unannounced fire drill during the months of June and July 2015.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from 2/20/2013, 1/13/2014, and 12/16/2014.
|
Plan of Correction
The TASC supervisors have now been assigned monthly duties for 2016 in which they will schedule, conduct, and document each respective fire drill as required by DDAP procedures. |
709.42(d) LICENSURE Hours of operation
709.42. Project management.
(d) The intake project shall operate at least 5 days of the week and for a minimum of 40 hours per week. Additional hours should be appropriate to the population served by the intake project.
|
Observations
Based on the review of the facility 's activities of intake, evaluation, and referral, the facility failed to operate at least 5 days of the week and for a minimum of 40 hours per week.
The finding included:
A physical plant inspection was conducted on March 16, 2016. The facility failed to operate at least 5 days of the week and for a minimum of 40 hours per week as the hours of operation posted were Monday to Friday 8 AM until 4:30 PM. The facility is operating at 37.5 hours per week.
These finding were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The hours of operation at TASC are from 8:00 AM until 4:00 PM, Monday through Friday. We do not close at any time during the day. Our staff stagger their half hour lunch periods so that service to the individuals we serve is never disrupted. We are available to the public 40 hours per week, and 5 days per week, as required. Thank you. |
709.43(b) LICENSURE Special Issues
709.43. Client management.
(b) The intake project shall have written policies and procedures to address special issues regarding treatment of clients. These policies and procedures shall include, but are not limited to:
|
Observations
Based on a review of written policy and procedures, the facility failed to have a written policy that addressed special issues regarding treatment of clients. These policies and procedures are to include, but are not limited to, individuals who lose consciousness, minors, individuals with communicable disease, individuals requiring transfer to hospital or other treatment facility, and individuals requiring detoxification.
The findings include:
A review of written policy and procedures was conducted on March 16, 2016. The facility failed to have a written policy that addressed special issues regarding treatment of clients at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
TASC has officially posted a written policy for all staff regarding the proper course of action when encountering an individual who has lost consciousness, needs hospitalization, is exhibiting overt symptoms of withdrawal, or who has a communicable disease. In most cases, TASC will contact 911, and will make said individual as safe and comfortable as possible until EMT staff arrives. TASC has also posted its written procedures when arranging transportation to a detoxification facility for an individual who is experiencing withdrawal symptoms. TASC will contact and provide a taxi cab voucher for individuals who will be admitted to a local detox facility, and will continue to contact the various detox facilities located outside of the Reading and Berks County area who send drivers to TASC to transport these individuals to their respective facilities. TASC will post and follow a written policy of how to properly address the needs of minors who present to the TASC agency. Minors presenting for services will be required to be accompanied by an adult, and the adult and minor will sign appropriate consent forms to ensure safety and confidentiality. |