INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the August 17, 2010 licensure renewal inspection. The follow-up inspection was conducted on April 21, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Spring-Ford Counseling 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 May 24, 2011.
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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 an interview with the project 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:
An interview was conducted with the facility director on April 21, 2011. She was asked if they had gotten an updated agreement that specified 24 hour emergency psychiatric services.
She advised they had not . As she was still waiting for the hospital to respond to the letter that had been sent out requesting 24 hour emergency psychiatric services. The facility was unable to provide a written agreement with a licensed hospital or physician for 24 hour emergency psychiatric services.
This is a repeat citation. The facility was previously cited on August 17, 2010 for failing to provide a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage.
In response to the citation issued on August 17, 2010, the facility's plan of correction submitted on 9/02/2010 and approved on 9/16/2010, stated the following:
"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 [sic] should not occur in the future."
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Plan of Correction
Within 45 days, the facility director shall contact and obtain a referral agreement from a 24 hour emergency licensed hospital which will specify psychiatric coverage. Once the referral agreement is signed, it would need to be updated every 2 years, Director will monitor dates to prevent outdated agreements. |
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 April 21, 2011 at 11:35 AM. 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.
This is a repeat citation. The facility was previously cited on August 17, 2010 for failing to provide hot water under pressure.
In response to the citation issued on August 17, 2010, the facility's plan of correction submitted on 9/02/2010 and approved on 9/16/2010, stated the following:
"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 [sic] will immediately be called to correct the problem. SFCS does have hot water, however spigot drips, spigot will be fixed within 60 days."
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Plan of Correction
This has been completed as of May 17. 2011. The hot water now has pressure.
Director will continue to visually monitor water pressure. If there is another plumbing issue, building maintenance will be notified and problem will be addressed in a timely manner. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of areas of noncompliance identified during this licensing inspection that had previously been cited, the facility failed to comply with prior plans of correction approved by the Department.
The findings include:
On April 21, 2011 the facility was again found to be out of compliance with the following standards:
1. 705.24(3) The facility was previously cited on August 17, 2010 for failing to provide hot water under pressure.
In response to the citation issued on August 17, 2010, the facility's plan of correction submitted on 9/02/2010 and approved on 9/16/2010, stated the following:
"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 [sic] will immediately be called to correct the problem. SFCS does have hot water, however spigot drips, spigot will be fixed within 60 days."
2. 709.24(d) Treatment/rehabilitation management (written agreement for the provision of 24 hour emergency medical and psychological coverage)
The facility was previously cited on August 17, 2010 for failing to provide a written agreement with a licensed hospital or physician for 24-hour emergency psychiatric and medical coverage.
In response to the citation issued on August 17, 2010, the facility's plan of correction submitted on 9/02/2010 and approved on 9/16/2010, stated the following:
"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 [sic] should not occur in the future."
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Plan of Correction
As previous Plan of Correction:
Within 45 days the facility director will contact and obtain a signed referral agreement with a 24 hour emergency psychiatric and medical coverage.
The water spigot, hot water now has pressure, this has been fixed as of 5/17/2011. |