INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 1, 2 and 3, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on May 25, 2007.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Employee #1 had not received the mandatory HIV/AIDS training within the one year time frame from date of hire.
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Plan of Correction
Employee #1 received the TB/STD/Hep training on April 20, 2007 at the Lancaster SCA offices and the HIV/AIDS training on May 8, 2007 at Roxbury treatment center in Shippensburg. Project Director will monitor compliance with training requirements during development of annual training plans and in individual employee evaluations. |
705.1 (3) LICENSURE Gen requirements for residential facilities.
705.1. General requirements for residential facilities.
The residential facility shall:
(3) Comply with applicable Federal, State and local laws and ordinances.
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Observations
The City of Harrisburg requires that the facility have sprinkler protection. The March 28, 2007 sprinkler report indicated that the facility has sprinkler heads that are part of a recall and need to be replaced.
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Plan of Correction
Recalled sprinkler heads were discovered by current Operations manager when reviewing report from last fire safety inspection. It was discovered that previous reports were missing and when one was found it was determined that previous Ops manager must have known about the situation and did not correct it. One quote has been received to replace the recalled sprinklers and will be taken along with at least one more quote to the June 25, 2007 meeting of the Board of Directors where a decision will be made regarding which company to hire to do the work which will be scheduled as soon as possible with a target of having work completed by 8/30/2007.
Operations manager will monitor compliance with fire safety standards and keep a file of all sprinkler and fire safety reports for continued reference. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Eight of twelve rubbish cans lacked lids to prevent the penetration of insects and/or rodents.
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Plan of Correction
lids were discovered stuffed behind rubbish containers after licensing visit.
Lids will be attached to containers or fence with security cables t prevent open containers. Operations manager will monitor compliance. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Bedrooms number 2, 3, and 6 had mattresses that were not flame retardant. Rooms 2 and 6 each had one mattress that was not flame retardant and room 3 had two.
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Plan of Correction
Our assumption is that clients removed the fire retardant tags on the mattresses. Records of mattress purchase could not be found to document that mattresses are fire retardant. In one room clients had put the fire retardant mattress underneath another mattress.
Operations manager will locate and purchase fire retardant mattresses and establish and maintain a file of purchased equipment |
705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
The evacuation plan did not include a procedure for the evacuation and transfer of residents impaired by alcohol or other drugs.
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Plan of Correction
Project director will evaluate and update evacuation plan to include procedure for transfer of residents impaired by alcohol or other drugs |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
The back patio exceeds an 18 inch drop and lacked a rail.The steps to the side walk on 18th Street lacked a handrail.
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Plan of Correction
Rail on back patio was put in place May 4, 2007.
Railing on 18th st. steps was delayed because of property issues with Reclaim the streets ministries which is the adjacent church building. Reclaim the streets owns the piece of land which contains the front steps and have granted Daystar access rights to that side of our building. Daystar requested permission from the church to place the railing along those steps and has not heard from Reclaim the Streets.
Project director will install the railing by the corrective action date. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Stairs and hallways have light switches where lights can be turned off.
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Plan of Correction
Facility will install key switches. Operations manager will oversee installation within 90 days of 6/1/2007 |
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
The last documented drill during sleeping hours was at 7/3/06.
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Plan of Correction
Drill conducted 1:15 a.m. May 12, 2007
Operations manager will oversee compliance with fire safety standards |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
One of five personnel records reviewed lacked a salary history.
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Plan of Correction
Project director will place salary history in employee's personnel file by 6/8/2007
Project director will monitor compliance during annual performance evaluations |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Employee #1 had not received an annual employee performance evaluation.
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Plan of Correction
Evaluation did not take place near anniversary date because of changeover in leadership of personnel committee of the Board of Directors.
Personnel committee chairperson will schedule and lead the evaluation by 7/30/2007
Compliance will be monitored by personnel committee |
709.26(d)(5)(ii) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(ii) The individual shall be informed, by written copy, of their annual evaluation.
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Observations
Employee #1 was not informed in writing of his/her annual performance evaluation.
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Plan of Correction
Personnel committee chairperson of the Board of Directors will inform employee #1 in writing of the results of his annual performance evaluation by 7/30/2007
Compliance will be monitored by the personnel committee and the Board of Directors |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
A discharge summary was missing in one of three records reviewed, #5.
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Plan of Correction
Clinical supervisor reviewed standard with clinical staff 5/4/2007 to insure that discharge summaries are completed for all clients.
Project Director will monitor to insure compliance |