INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28-29, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection Pennsylvania Organization for Women in Early Recovery 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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704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
The facility failed to maintain FTE counselor caseloads for outpatient counseling at or below 35:1.
The Staffing Requirements Facility Summary Report was reviewed on January 28 & 29, 2020. Based on the total number of hours per week devoted to clients, and the facility's standard work week of 37.5 hours, employee # 5 exceeded the allowable maximum 35:1 caseload.
-As reported on the Staffing Requirements Facility Summary Report, the number of hours per week devoted by Employee # 5 to outpatient client treatment was 30 hour per week. The employee had 31 active client as of January 28, 2020.
-Employee # 5 (30/37.5 = .8 FTE *** 31 clients/.8 FTE = 39/1 caseload)
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility corrected the issue by 2/4/2020. The facility will maintain FTE counselor caseloads for outpatient counseling at or below 35:1 at all times moving forward. The facility understands that caseloads must be at or below the appropriate ratio at all times. It is the responsibility of the Facility Director to insure that FTE caseloads of all full and part time counselors remain at or below 35:1 at all times. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to document that the fire alarm was activated and the exit route used for each monthly fire drill conducted.
The fire drill logs were reviewed on January 28, 2020. The drills conducted in the months of November 2019, December 2019 & January 2020 had no exit route documented and there was no documentation that the fire alarm was activated. No exception to the regulation was documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has requested an exemption from the requirement to activate the fire alarm at each drill due to it being an interlocking fire alarm system that would cause all other businesses located within the building to have their alarms activated. While waiting for this exemption to be approved or denied, the facility has begun utilizing a smaller fire alarm typically used in residential homes to set off during the drills monthly. If the exemption is not approved, this smaller alarm will be used permanently. It is the responsibility of the CFO to ensure that this corrective action plan is implemented. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to document that unusual incident reports were sent to the Department within 3 business days following incidents involving the presence of an ambulance.
The unusual incident reports were reviewed on January 28, 2020. There were two unusual incidents that occurred on October 8 and October 18, 2019 in which an ambulance was called. There was no documentation that the unusual incident report was sent to the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will submit incident reports for all unusual incidents involving the presence of an ambulance at the facility. The facility will use DDAP's online incident reporting system moving forward to insure that all reports are received by the Department within the required time frame. The facility will no longer fax incident reports to the department and will use email if unable to submit through DDAP's online incident reporting system for any reason. All staff have been re-trained on the reporting of unusual incidents as of 02/13/2020. It is the responsibility of the Clinical Director to ensure that this corrective action plan is implemented. |