INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 20-21, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Salvation Army Harbor Light Center 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 May 12, 2009.
|
Plan of Correction
|
709.32(c)(5) 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:
(5) Security of drugs.
|
Observations
Based on a review of the policy and procedure manual, the facility failed to document a policy regarding the security of all drugs.
The findings include:
A review of the policy and procedure manual was conducted on April 20-21, 2009. Policy regarding the security of all drugs, specifically loss, theft or misuse, is required for inpatient facilities. The facility did not document a security of all drugs policy.
|
Plan of Correction
Institutional Services Director shall develop and add a section tomeet 709.32 (c)(5)security of drugs that includes loss, theft, or misuse of drugs.
Institutional Services Director shall review policy with Medical Director.
Institutional Services Director shall present the above to the Salvation Army Institutional Services Board for approval, at its next scheduled meeting on September 16, 2009
Institutional Services Director shall review 709.32(c)(5) with clinical staff.
A copy of 709.32 (c)(5) shall beincorporated into the the Agency Policy and Procedure Manual. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
A review of the fire drill logs was conducted on April 21, 2009. Documentation of a fire drill conducted during sleeping hours is required once every six months. The facility did not document any fire drills during sleeping hours in the last twelve months.
|
Plan of Correction
Facility will conduct at least (1) one fire drill every (6) six months during sleeping hours.
Institutional Services Directror will direct the Administrative Assistant to have the night desk/security personel conduct a fire alarm during sleeping hours at least every (6)six months and document the fire drill.
The Institutional Sdervices Director shall freview and initial the re3sults of all fire alrams. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
|
Observations
Based on client record review and staff interview, the facility failed to document a six month follow up in three of three client records.
The findings include:
Twelve inpatient client records were reviewed and an interview with the counselor, took place on April 20, 2009. Documentation of a six month follow up was required in three client records. The facility did not document a six month follow up in client records # 5, 6 and 11. This was confirmed by the counselor during the interview with licensing personnel.
Client #5 was discharged on 9/5/08 and six month follow up was due on 3/5/09 but had not been documented as of April 21, 2009.
Client #6 was discharged on 9/11/08 and six month follow up was due on 3/11/09 but had not been documented as of April 21, 2009.
Client #11 was discharged on 10/18/08 and six month follow up was due on 4/18/09 but had not been documented as of April 21, 2009.
.
|
Plan of Correction
Institutional Services Director shall have the Clinical Supervisor meet with counseling staff to review licensing requirement for (6) six month client follow-up.
Primary counselor shall be responisble to complete a (6) six month follow-up will each client.
Clinical Supervisor shall review client charts monthly with each counselor to insure a (6) six month follow-up (telephone or leter)is completed and documented in the clint file. |