INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 24 - 26, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Davis Archway House 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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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the facility's policy and procedure manual on August 24, 2011, the facility failed to document a training procedure which included the timeframes for the required components. The findings include:The facility training policy and procedure was reviewed during the annual licensing inspection on August 24, 2011. The procedure did not include documentation of time frames for completion of the assessment component, the overall plan component and the feedback. This was discussed with and confirmed by the project director on 8-25-2011 at 2:30 PM.
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Plan of Correction
The facility policy and procedure manual will be updated to reflect the timeframes for completion of the assessment, overall plan and feedback. 704.11(a)(1) has been set to begin the first day of June of each year and will be completed by June 15th. 704.11(a)(2) will be developed after the assessment is complete and will be done by the end of June. Section 704.11(a)(3) will reflect that feedback from trainings will be given to the employee and collected within 30 days of attendance. This will be updated and complete by October 1, 2011. |
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 logs, the facility failed to conduct a fire drill during sleeping hours at least once every six months.The findings include:Fire drill logs were reviewed on August 25, 2011. Documentation of a fire drill conducted during sleeping hours is required once every six months. The fire drill logs from September 2010 to August 2011 were reviewed. During that time frame, the facility documented only one fire drill during sleeping hours. This was discussed with and confirmed by the project director on 8-25-2011 at 9:00 am.
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Plan of Correction
The facility will conduct a fire drill during sleeping hours for the month of September 2011. The Facility Director will ensure the night staff are scheduled to have drills during sleeping hours at least once every 6 months. This will be documented in the fire drill log. The facility will have this completed by October 1, 2011. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the annual report, the facility failed to make the annual report available to the public. The facility also failed to include a financial statement of income and expenses, and a statement disclosing the names of officers, directors and principal shareholders. The findings include:The annual report for 2010 was reviewed on August 24, 2011. The annual report was not made available to the public. The facility also failed to include a financial statement of income and expenses, and a statement disclosing the names of officers, directors and principal shareholders, where applicable. This was discussed with and confirmed by the director on August 24, 2011 at 2:30 PM.
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Plan of Correction
The facility annual report will be made available to the public, notice of this will be posted on the facility website. The report will be modified to include a financial statement of income and expenses, and a statement disclosing the names of officers, directors and principle shareholders. The Facility Director shall have this completed by October 1, 2011. |
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
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Observations
Based on a review of the facility's policy and procedure, the employee handbook, personnel records, and a conversation with the project director, the facility failed to demonstrate the project's efforts towards informing staff of their rights. The findings include: The policy and procedure, the employee handbook, a review of four personnel records and a conversation with the project director, all occurred on August 24, 2011. The employee handbook signature page was documented in four of the four personnel records reviewed, but the employee rights are not included in the handbook. This was discussed with and confirmed by the director on August 24, 2011 at 3:00 PM.
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Plan of Correction
The employee handbook will be modified to include employee rights. In the handbook, all staff will be notified of their right to inspect their records, the procedure to access these records and also the right to request correction and submit rebuttal data. The Facility Director will complete this by October 1, 2011. |
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 the facility's policy and procedure, the client handbook, eight client records, and a conversation with the project director, the facility failed to demonstrate the project's efforts towards informing clients of their rights. The findings include: The policy and procedure, the client handbook, a review of eight client records and a conversation with the project director, all occurred on August 24, 2011. Four of the client records were required to include documentation that clients were informed of their rights. The client handbook signature page was documented in four of the four client records reviewed, but the client rights included in the handbook do not include that the project director may temporarily remove portions of the records prior to the client's inspection of his/her record, or that the client has a right to appeal a decision to limit his/her access to his/her record to the project director. The facility did not document that clients were informed of their rights in client records #1, 2, 3, and 4. Client #1 was admitted on June 3, 2011 and discharged on July 21, 2011. The client record failed to include documentation that the client was informed of his/her rights.Client #2 was admitted on July 22, 2011 and discharged on August 17, 2011. The client record failed to include documentation that the client was informed of his/her rights.Client #3 was admitted on July 25, 2011. The client record failed to include documentation that the client was informed of his/her rights.Client #4 was admitted on June 22, 2011. The client record failed to include documentation that the client was informed of his/her rights.This was discussed with and confirmed by the director on August 25, 2011 at 3:00 PM.
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Plan of Correction
The Client Rights section in the client handbook will be modified to include the project director may temporarily remove portions of the records prior to the clients inspection of his record, and also modified to include that clients have a right to appeal a decision to limit his access to his record to the project director. All clients will be informed of this right, the Facility Director shall have this updated by October 1, 2011. |
709.32(c)(3) 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:
(3) Inspection of storage areas.
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Observations
Based on a review of the policy and procedure manual and an interview with the facility director, the facility failed to document inspections of the medication storage area.The findings include:On August 24, 2011, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an inspection of the medication storage area will be completed and documented quarterly by the facility director. The facility failed to document any inspections of the medication storage area. The facility director confirmed that medication storage area inspections were not documented.
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Plan of Correction
The Facility Director will schedule a quarterly inspection of the medication storage area and will be responsible for documentation once completed. The storage area will have a documented inspection by october 1, 2011 and will continue on a quarterly basis. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document that work done by the client at the project was an integral part of the treatment and rehabilitation plan in four of eight client records.The findings include:Eight records were reviewed on August 25, 2011. Verification of work as an integral part of the treatment and rehabilitation plan was required in four client records. The facility did not document work as an integral part of the treatment and rehabilitation plan in client records #1, 2, 3 and 4. Client #1 was admitted on June 3, 2011 and discharged on July 21, 2011. The client record failed to include documentation that the work done by the client at the project was an integral part of the treatment and rehabilitation plan.Client #2 was admitted on July 22, 2011 and discharged on August 17, 2011. The client record failed to include documentation that the work done by the client at the project was an integral part of the treatment and rehabilitation plan.Client #3 was admitted on July 25, 2011. The client record failed to include documentation that the work done by the client at the project was an integral part of the treatment and rehabilitation plan.Client #4 was admitted on June 22, 2011. The client record failed to include documentation that the work done by the client at the project was an integral part of the treatment and rehabilitation plan.This was discussed with and confirmed by the project director on 8-25-2011 at 3:00 PM.
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Plan of Correction
Client treatment plans will be modified to include work therapy as part of their rehabilitation. This will continue to be updated in treatment plan updates as client progress through the treatment program. This will be fully implemented by october 1, 2011. |