INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6, 2014 and August 11, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, DARS, Inc. Supervised Independent Living Program 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:
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Plan of Correction
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705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on an observation during the physical plant inspection, the facility failed to provide paper towels or a mechanical dryer and hand soap in each bathroom.
The findings include:
A physical plant inspection was conducted on August 6, 2014 at approximately 9:30 AM.
The facility failed to provide paper towels or a mechanical hand dryer and an operable soap dispenser in the first floor bathroom behind the reception desk.
The facility director confirmed the findings.
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Plan of Correction
The Facility Director will ensure that the existing paper towel dispenser in the first floor bathroom remains stocked with paper towels at all times. A permanent soap dispenser will be mounted to the wall adjacent to the sink no later than August 29th, 2014. In the event that the soap dispenser becomes broken or inoperable, pump bottles of hand soap will be placed in the bathroom until the dispenser can be repaired or replaced. The Youth Care Supervisor will be responsible for daily checks to ensure that the soap dispenser, toilet paper, and paper towels are stocked in the bathroom. Toilet paper, paper towels, and hand soap were placed in the bathroom on August 5th, 2014, immediately after it was discovered that they were missing. |
705.7 (b) (6) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(6) Store all food items off the floor.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that all food items were stored off of the ground.
The findings include:
A physical plant inspection was conducted on August 6, 2014 at approximately 9:30 AM.
Two 8.5 ounce aluminum cans of fruit cocktail were resting on the tile floor below the lowest metal shelve in the back left corner of the canned food storage area in the kitchen.
The facility director confirmed the findings.
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Plan of Correction
All food items will continue to be stored on approved shelving units in the food storage area. The cook will ensure that all food items remain placed on the appropriate shelves when not in use and that no food items come in contact with the floor. This will be conducted at any point that food is being taken from or placed in the food storage area. |
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
Based on a review of fire drill records and staff interviews, the facility failed to conduct a fire drill during sleeping hours within the past six months.
The findings include:
The sleeping hours for the clients are Monday - Friday range from 9:15 PM - 6:00 AM as per the facility program schedule. All of the fire drills documented from January 2014 - July 2014 were conducted on a week day. The facility failed to conduct a fire drill during sleeping hours from January 2014 - July 2014. The last fire drill the facility conducted during sleeping hours was on December 20, 2013 at 2:44 AM.
The facility director and project director confirmed the findings.
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Plan of Correction
The Facility Director will ensure that at least one fire drill will be conducted during the overnight hours during every six month period. The scheduled fire drill for the month of August 2014 will take place on August 27, 2014 during sleeping hours. The Facility Director and the Youth Care Supervisor will discuss the scheduled fire drills for the upcoming month durig monthly Supervisor's meetings. This will ensure that overnight fire drills are conducted at least once every six months. The Youth Care Supervisor and Facility Director will meet the day following each overnight fire drill to confirm that it was conducted appropriately. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document a treatment plan update at least every 30 days in five of nine client records.
The findings include:
Nine client records which required documentation of a treatment plan update were reviewed on August 11, 2014. The facility failed to document a treatment plan update at least every 30 days in client records # 1, 4, 5, 8 and 10.
Client # 1 was admitted on 3/3/14 and discharged 6/19/14. The last two treatment plan updates for client # 1 were completed on 5/27/14 and 4/18/14.
Client # 4 was admitted on 11/18/13 and discharged 4/2/14. The last two treatment plan updates for client # 4 were completed on 3/31/14 and 2/28/14.
Client # 5 was admitted on 1/29/14 and discharged 6/5/14. The last two treatment plan updates for client # 5 were completed on 5/12/14 and 4/10/14.
Client # 8 was admitted on 4/10/14 and was still an active client at the time of the inspection. The last two treatment plan updates for client # 8 were completed on 7/17/14 and 6/3/14.
Client # 10 was admitted on 1/27/14 and was still an active client at the time of the inspection. Treatment plan updates for client # 10 were completed on 6/25/14 and 5/8/14.
The project director confirmed the findings.
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Plan of Correction
The Clinical Supervisor will ensure that all treatment plan updates are updated within thirty days of the previous treatment plan. The Clinical Supervisor or Senior Counselor will continue to sign the treatment plan update, in addition to the client and the primary counselor. SOP 709.24 a (3) was updated on August 22, 2014 to reflect this regulation. The Clinical Supervisor will inform all SIL clinical staff members of this correction effective August 22, 2014. |