INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on March 29 & April 1, 2019. Based on the findings of the on-site inspection, Spanish American Civic Association For Equality, Inc was found to not 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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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
The facility failed to maintain the floor in the client's lounge in a state of good repair.
Several tiles were cracked and broken at the emergency exit door.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The tiles were replaced by maintenance on 4/12/2019.
The house will have a weekly walk through completed by clinical supervisor going forward and any repairs needed will be reported to the executive director for immediate repair. |
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.
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Observations
During an onsite annual licensing renewal on March 28 & April 1, 2019, the facility failed to conduct a drill during sleeping hours every 6 months.
There were no sleeping fire drills documented from January 12, 2018 through March 13, 2019.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor performed drills between 9-11pm. Executive Director met with clinical supervisor and retrained on third shift fire drills. Clinical supervisor or 3rd shift staff will perform fire drills between hours of 11pm and 5am beginning with April fire drill. Director will monitor fire drill reports for compliance of sleeping hours drills before signing off going forward |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
During an onsite annual licensing inspection on April 1, 2019, the facility failed to secure the client's records within a locked storage cabinet.
The client records which were kept in a cabinet in the foyer of the building were left unattended and unlocked.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Lock on cabinet was repaired and ALL staff retrained on keeping cabinet locked in addition to the door to the room which is always locked. Random checks daily will take place by clinical supervisor for the next 6 months then weekly checks will take place |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During an onsite annual licensing inspection seven client records were reviewed on March 28 & April 1, 2019, the facility failed to ensure that they had written policies and procedures to address all client rights.
Client #1 was admitted on November 21, 2018 and was active at the time of the inspection. Client #1 had not been informed that the project does not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #2 was admitted on November 23, 2018 and was active at the time of the inspection. Client #2 had not been informed that the project does not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #3 was admitted on December 10, 2018 and was active at the time of the inspection. Client #3 had not been informed that the project does not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #4 was admitted on March 15, 2018 and was discharged on September 28, 2018. Client #4 had not been informed that the project does not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #5 was admitted on June 4, 2018 and was discharged on October 2, 2018. Client #5 had not been informed that the project does not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #6 was admitted on June 27, 2018 and was discharged on October 20, 2018. Client #6 had not been informed that the project does not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
Client #7 was admitted on August 8, 2018 and was discharged on November 18, 2018. Client #7 had not been informed that the project does not discriminate on the basis of age, creed, ethnicity, national origin, marital status or sexual orientation.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All current clients were given and signed new client rights forms that were updated. All old forms discarded.
Master chart update again to reflect correct verbiage on forms Office Manager retrained to make sure the correct forms are being completed. Clinical Supervisor to audit charts weekly for compliance |