INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 26, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Another Way, Inc 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 September 25, 2009.
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Plan of Correction
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705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of fire drills logs, the facility failed to document that the fire alarm or smoke detector was set off during each fire drill.
Findings:
The fire drill logs were reviewed on August 26, 2009. The logs documented that the fire drills were verbally announced for the months of April, May, June and July 2009. There was no documentation that the fire alarm or smoke detector was set off during each fire drill.
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Plan of Correction
Observation #P155
The facility was conducting fire drills on a monthly basis, but was conducting them verbally. The administrative assistant will contact the fire alarm company and set up the procedure to manually set off the alarm during the dire drills. All staff will be given a memo explaining the procedure to set off alarm and the need to set the alarm system off. The Lead Therapist will ensure all staff will be in full compliance by September 25, 2009. The administrative assistant and facility director will supervise that the alarms are being set off during each fire drill. |
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
Based on a review of the audit for July 1, 2007 through June 30, 2008, the project failed to complete an audit by the end of the project's fiscal year.
The findings include:
A review of the annual audit was conducted on August 24, 2009. The project's audit for July 1, 2007 through June 30, 2008 was due to be completed no later than December 30, 2008. The project's audit was not completed until August 12, 2009.
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Plan of Correction
Observation#0169
Due to our previous auditing company being unable to complete the audit, we needed to gain another auditor which was unfamiliar with our accounting systems. The fiscal officer is working with the auditors on the 08/09 audit. The Project Director will oversee the audit to ensure that the December 30,2009 deadline is met. We are currently in compliance this year as demonstrated by the work being started on this audit. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the client handbook and bulletin board postings, the facility failed to inform clients of their right to submit rebuttal data or memoranda to their record and the right to not be discriminated against in the provision of services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion in six of six client records.
The findings include:
Six client records were reviewed on August 26, 2009. A review of the client handbook and bulletin board postings was also conducted on August 26, 2009. Clients are required to be informed of all of their rights including their right to submit rebuttal data or memoranda to their record and the right to not be discriminated against in the provision of services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. These two rights were found in the policy and procedure manual, however, there was no documentation that this information was provided to the clients in client records # 1, 2, 3, 4, 5 and 6.
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Plan of Correction
Observation#0297
The clients rights in the client handbook and posted on the walls at Another Way did not contain a memoranda that the resident had a right to add a rebuttal. The client rights have since included these pieces and are posted in the client sitting area. A copy of the client rights will be given to all clients in their client handbook upon admit and a signature page from the handbook is kept in the record. The administrative assistant will ensure that all clients when admitted receive the handbook. The facility director will ensure the rights remain posted on the wall in client sitting area. The facility will be in full compliance by September 7, 2009. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to document that a physical examination was completed, prior to admission, in two of six client records.
Findings:
Six client records were reviewed on August 26, 2009. Six client records were required to have a physical examination documented. There was no documentation that a physical examination was completed in client records # 3 and 6.
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Plan of Correction
Observation # 1757
In records #3 and #6 the documentation did not met the standard for a physical examination. The intake worker and administrative assistant were educated on the specific requirements to be counted as a physical exam. They will assure the paperwork is received and completed before the client is admitted to Another Way. The agency will be in full compliance by September 7, 2009. The administrative assistant will include the physical exam as part of her monthly chart audit. This will be monitored by the Lead Therapist. |