INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Alcohol and Drug Abuse 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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705.24 (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 the physical plant inspection, the facility failed to ventilate the staff bathroom by an exhaust fan or window.
The findings include:
The physical plant inspection took place on January 15, 2015. The facility did not have an operating exhaust fan or window in the staff bathroom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Immediately upon notification that the ventilation in the staff bathroom at Maple Manor was not working properly the Inpatient Supervisor contacted the building maintenance department and the problem was corrected the same day as the facility inspection. The Inpatient Supervisor will continue to monitor compliance with physical site standards through use of a compliance checklist and completion of monthly inspections. The Executive Director will also complete periodic facility inspections at all sites to ensure compliance. Alcohol and Drug Abuse Services is in full compliance with these standards as of February 3, 2015. |
709.53(a) LICENSURE Complete Client Record
709.53. 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:
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Observations
Based on the review of client records, the facility failed to provide a complete client record on each individual in one of five client records.
The findings include:
Five client records were reviewed on January 15, 2015. One client record was reviewed for the Outpatient Drug-Free activity. Four client records were reviewed for the inpatient non-hospital - residential treatment activity, and complete client records were required. The facility did not provide a complete client record for record #3.
Client #3 was admitted to treatment on October 27, 2014 and was discharged on November 10, 2014. The facility failed to document client #3 ' s case consultation.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director/Facility Director reviewed the discrepancy regarding failure to document client #3 ' s case consultation with the Inpatient Supervisor. The Inpatient Supervisor was instructed that case consultation must be documented the same day immediately following the staffing meeting in which the consultation occurs. The Inpatient Supervisor will provide follow up training to all staff at the next departmental staffing meeting. The Inpatient Clerical Staff will utilize a checklist developed by the Inpatient Supervisor to review files for completion of documentation including case consult documentation on a bi-weekly basis. The Clerical Staff will notify the Inpatient Supervisor of any missing documentation. The Inpatient Supervisor is responsible for ongoing monitoring and reviewing each client's file to ensure compliance. The Executive Director/Facility Director will also conduct periodic file reviews to monitor compliance. |