INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 16, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Cen-Clear Child 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.
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Plan of Correction
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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
Based on a review of fire drill records, the facility failed to maintain a fire drill record that included the time of the fire drill.
The findings include:
Fire drill records were reviewed on August 16, 2012 for the period August 2011 through July 2012. The facility failed to document the time of the drill for the fire drills conducted on the following dates: September 20, 2011, October 13, 2011, November 29, 2011, December 8, 2011 and January 27, 2012.
The project director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Facility Director implemented a new fire drill log/form February 2012 that has separated out the date and time,number of participants and if there was any issues during the drill. The Facility Director will be responsible for reviewing this log on a quarterly basis for completeness. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow-up information in three of three client records.
The findings include:
Seven client records were reviewed on August 14 - 15, 2012. Three client records were closed and required documentation of follow-up information. Per agency policy, a follow-up will be conducted within 7 days of discharge. The facility failed to document follow-up information in client records # 5, 6 and 7.
Client # 5 was admitted into treatment on January 13, 2012 and discharged on April 10, 2012. A follow-up attempt was due to be completed no later than April 17, 2012. There was no documentation of follow-up information in client record # 5.
Client # 6 was admitted into treatment on May 23, 2011 and discharged on February 25, 2012. A follow-up attempt was due to be completed no later than March 3, 2012. There was no documentation of follow-up information in client record # 6.
Client # 7 was admitted into treatment on January 12, 2012 and discharged on June 13, 2012. A follow-up attempt was due to be completed no later than June 20, 2012. There was no documentation of follow-up information in client record # 7.
The facility director was interviewed throughout the licensing inspection and confirmed the findings.
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Plan of Correction
The Facility Directorh has updated the follow-up policy on July 9, 2012 that reflects that follow-ups will be conducted by the departmental assistants on all consumers that have been discharged at 30 day and 6 month following discharge. The policy also states the if a referral is made to an outside agency then a follow-up will be completed departmental assistants within 7 days of discharge. In addition, the Facility Director has implemented a tracking system that tracks the completion of follow-ups with the departmental assistants. |