INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 17, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Spring-ford counseling Services Inc., 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 September 20, 2010.
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Plan of Correction
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709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of administrative policies and procedures and an interview with the project and facility director, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric coverage.
The findings include:
The administrative policies and procedures were reviewed on August 18, 2010. The facility was unable to provide a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric services.
The facility director confirmed the program did not have a referral agreement that specified 24 hour emergency psychiatric coverage.
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Plan of Correction
Within 60 days, the facility director shall contact and obtain a referral agreement from a 24 hour emergency licensed hospital which will specify psychiatric coverage. The referral agreement will be updated every two (2) years there after, therefore defiency should not occur in the future. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to ensure the nonresidential facility had hot water under pressure.
The findings include:
A physical plant inspection was conducted with the facility director on August 18, 2010 from 2:05 PM until 2:20 PM. Per regulation, the nonresidential facility shall have hot and cold water under pressure. The facility had one unisex bathroom designated for staff and clients. During the physical plant tour, the inspector attempted to verify that hot and cold water was available. Upon turning the spigot that was determined to generate hot water it was discovered that there was no water flow. A similar attempt to operate the spigot designated for cold water generated a flow of water.
In an interview, the facility director confirmed that there was no hot water available in the bathroom.
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Plan of Correction
Within 60 days, facility director will request building maintenance to inspect and fix water spigot in bathroom. Facility director will continue to visually inspect water spigot for malfunctions, if spigot appears to be malfunctioning, maintentance will immediately be called to correct the problem.
SFCS does have hot water, however spigot drips, spigot will be fixed within 60 days. |
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 an inspection of the facility's physical plant and an interview with the facility director, the facility failed to ensure all exits were unobstructed.
The findings include:
A physical plant inspection was conducted with the facility director on August 18, 2010 from approximately 2:05 PM until 2:20 PM. The facility is in a single-level office. During the inspection it was found that the second exit had to be accessed through the office of the project director. The sole entry to the office which contains the second exit is through a door which can be locked from inside the room, effectively obstructing access to the second exit.
The facility director was asked if the door leading to the second exit could be locked and she confirmed it could be locked from inside the room.
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Plan of Correction
Within 60 days, facility director will ensure that there will be no lock on the door of the project director's office, therefore obstructing access to second exit will not exist. Facility director will purchase a new door handle, one that does not have a lock and replace the locking door handle. Facility director will contact building maintenence to switch door handles. Once door handle is replaced, this will ensure that exit will not be obstructed due to a locked door. |
705.28 (a) (1) (iv) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on an inspection of the facility's physical plant, the facility failed to clearly indicate exits by the use of signs.
The findings include:
A physical plant inspection was conducted with the facility director on August 18, 2010 from around 2:05 PM until 2:20 PM. During the inspection it was found that the second exit had to be accessed through the office of the project director and there was no indication of that second exit when the door to the facility director's office is closed. The second exit is obscured by a closed door and there were no signs to point the way to the second means of egress.
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Plan of Correction
With in 30 days, project director will purchase a EXIT sign to be located on or near the door of the facility director's office to ensure that when the door is closed, individuals will be aware of where the second exit is located. Once the EXIT sign is placed above or on the door it will not be taken down, this will ensure this deficiency does not recur in the future. |
709.93(a)(9) LICENSURE Client records
709.93. 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to document aftercare plans which included documentation of support services, a contact person and a re-entry process in three of three outpatient client records.
The findings include:
Five client records were reviewed on August 18, 2010. Three records were required to include documentation of aftercare plans which included support services, a contact person, and the re-entry process. The facility failed to document an aftercare plan which includes support services, a contact person, and the re-entry process in three of three outpatient records.
Client # 3 was admitted on May 25, 2010 and discharged on July 6, 2010. The aftercare plan was completed on July 6, 2010 and did not include documentation of a contact person or the re-entry process.
Client # 4 was admitted on April 6, 2010 and discharged on May 19, 2010. The aftercare plan was completed on May 19, 2010 and did not include documentation of support services, a contact person or the re-entry process.
Client #5 was admitted on May 24, 2010 and discharged on July 26, 2010. The aftercare plan was completed on July 26, 2010 and did not include documentation of support services, a contact person or the re-entry process.
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Plan of Correction
Within 30 days, the project director will update/change aftercare plan to include support services, contact person and re-entry process. New aftercare plan form will be reviewed at next team meeting within 30 days, to ensure compliance with regulations. Once updated/changed aftercare plan is completed it be incorporated in all new and existing client files to be completed towards the end of therapy. Facility director will complete periodic chart reviews to ensure compliance with regulations. |