INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 31, 2009 and September 1, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Women's Institute for Family Health 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 October 5, 2009.
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Plan of Correction
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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
Based on a physical plant tour conducted on September 1, 2009 at approximately 2:30 p.m., the facility failed to ensure that all trash, garbage and rubbish was stored in noncombustible, covered containers to prevent the penetration of insects and rodents.
Findings:
A physical plant tour was conducted on September 1, 2009 at approximately 2:30 p.m.. It was observed that trash was being stored in two dumpsters that did not have lids to contain and cover the contents of the dumpsters.
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Plan of Correction
The facility shall assure that all trash is stored in noncombustible covered containers. WIFH will store its trash in containers separate from the school facility and will dispose of trash weekly as per the city's trash pick up schedule. The Project Director will be responsible for the storage of trash and weekly disposal. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on observation during a physical plant tour conducted on August 31, 2009 the facility failed to provide ventilation in one of the bathrooms.
Findings:
A physical plant tour was conducted on August 31, 2009 at approximately 11:45 a.m.. During the physical plant tour it was observed that one of three bathrooms lacked a means to ventilate the bathroom. The staff bathroom located near the employee break room lacked a window or exhaust to ventilate the bathroom.
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Plan of Correction
The Project Director shall assure that a exhaust fan is intalled in the cited bathroom. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant tour conducted on August 31, 2009 and a physical plant tour conducted on September 1, 2009, the facility failed to ensure that exits were unobstructed.
Findings:
The facility shares space with a clinic that is located inside a high school building. The facility has one exit to the outside and the second exit is accessed by going through the school corridor system and utilizing one of the school's 9 sets of exit doors to the outside. During the August 31, 2009 physical plant tour of the facility and school, it was observed that the exit doors from the school were all locked with padlocks against egress with the exception of two doors at the opposite end of the building. There were exit signs throughout the school directing persons to the locked exits. During the September 1, 2009 physical plant tour additional exits were unlocked; however, there still was no clear way of knowing what ones would be left open.. The facility ans school were negotiating a plan to leave certain exits open and clearly indicate what ones they would be following the exit conference.
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Plan of Correction
The Executive Director will receive written confirmation from the school that exits in the area of the facility will be unlocked when the facility is open. WIFH will assure that exits will be clearly marked. WIFH has been in constant communication with the school district and has been informed that this situation will be rectified by school administration. WIFH anticipates a final response from the district within the week. |
705.28 (a) (1) (iii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential 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
Based on observation during a physical plant inspection on 9/1/09 at 12:55 p.m., the facility failed to ensure that well-secured railings were provided for each porch that had over an 18 inch drop and that well-secured handrails were provided for outside steps exceeding two steps.
Findings:
A physical plant tour was conducted on 9/1/09 at 12:55 p.m. The facility failed to provide a well-secured railing for the landing at exit #7 and to provide well-secured handrails for the four (4) steps from the landing to the grade.
Exit #7 from the school building is an alternative emergency exit from the facility.
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Plan of Correction
he Executive Director will assure that a railing is installed at exit #7. In speaking with school maintenence we have been advised that railings are scheduled to be installed. |
705.28 (c) (2) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
(ii) The extinguisher shall be located near an exit and away from the cooking area.
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Observations
Based on a physical plant tour on 8/31/09, the facility failed to provide inspected and approved type ABC fire extinguishers in the facility.
Findings:
During the physical plant inspection of the facility on 8/31/09 it was discovered that there were no inspected and approved fire extinguishers. On 9/1/09, the facility did provide appropriate fire extinguishers that had been inspected and approved by Philadelphia and PA Fire Protection Company to August of 2010.
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Plan of Correction
Approved Fire Extinguishers have been installed in the facility. The Executive Director shall assure that if the facility relocates in the future that the new location shall have approved fire extinguishers. |
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 an interview with the project director on September 9, 2009 the facility failed to document an independent financial audit for Fiscal Year 2008.
Findings:
The facility ' s fiscal year runs from January 1 through December 31. The facility ' s independent financial audit was to be completed within six months of the end of the fiscal year. The project director stated that the facility had not had an independent audit completed for the 2008 fiscal year.
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Plan of Correction
The Project Director shall assure that the facility obtain an audit for the current fiscal year The Project Director has solicited proposals from independent auditing company's for the purpose of hiring a company to conduct an audit for fiscal year 2009 that will end on December 31, 2009. The Project Director will select and contract with an auditing company by November 15, 2009 and will assure that an audidt for fiscal year 2009 will be completed by june 30, 2010. To prevent reourrence of this deficiency the Executive Director will solicit bids from auditing companies by October 15th of every year and select and contract with an auditing company by November 15th of every year to conduct an annual audit for each fiscal year ending December 31st. the Project Director will assure that audits are completed within 6 months following the end of the facility's fiscal year. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on the review of four client records on September 1, 2009 the facility failed to document a treatment plan update within 60 days of the completion of the individualized comprehensive treatment plan as per facility policy and procedure.
Findings:
Facility policy and procedure stated that treatment plan updates are to be completed within 60 days of the completion of the individualized comprehensive treatment plan.
Four client records were reviewed on 9/1/09, of those four records, two (2) were reviewed for treatment plan updates. One of two records, #1, lacked documentation of a treatment plan update.
The individualized comprehensive treatment plan for client #1 was completed on January 22, 2009 and the treatment plan was due on March 22, 2009. The treatment plan update was not completed until May 19, 2009.
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Plan of Correction
The Project Director shall assure that updates are completed as per agency and division 60 day policy. The facility has retained a new Clinical Director who will be responsible for assuring that forms are completed as required. This will be accomplished through weekly chart reviews. |