INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 5, 2015 and January 6, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Adappt House 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:
|
Plan of Correction
|
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that all structures on the facility grounds were free from any danger to health and safety.
The findings include:
The physical plant inspection occurred on 1/6/15. There were five 6" by 6" floor tiles outside of the first shower on the left that were significantly loose to the point that the tiles were protruding from the floor when stepped on. These loose tiles present a tripping and cutting hazard to clients entering and leaving the shower area.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Floor tiles are scheduled to be replaced by the Maintenance Suprvisor by January 31, 2015.
Security staff will perform a daily visual check of bathroom/shower areas to ensure there are no hazards to clients.
Any/all perceived hazards shall immediately be communicated to the Maintenance Supervisor. The Maintenance Supervisor shall ensure these issues are dealt with as quickly as possible. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
|
Observations
Based on a physical plant inspection, the facility failed to ensure the facility grounds were in good repair.
The findings include:
A physical plant inspection was conducted on 1/6/15. Department staff observed the following deficiencies:
There were not window blinds on the window above Bed C in Room 9.
The window blinds on the window in Room 8 were significantly damaged and were not fully functional.
The push bar mechanism on the door in the CBG room in the men's wing was in disrepair and was not fully functional.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Maintenance has replaced the window blinds above Bed C in Room 9 and Room 8. Maintenance will continue to do a daily, visual check of "blinds" to ensure that blinds in disrepair or missing are replaced as quickly as possible.
Staff other than Maintenance has also been instructed to be pro-active and report any and all "blind" issues.
A new push-bar was ordered and is due to be installed on 1/29/15. Going forward, and in order to be pro-active another new push-bar has been ordered to be held in stock in the event of another malfunction.
|
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of personnel records, the facility failed to document the instruction of staff in the use of fire extinguishers upon employment in two of five personnel records reviewed.
The findings include:
Five personnel records requiring the documentation of fire extinguisher training upon employment were reviewed during the renewal inspection on 1/5/15. The facility failed to document the completion of fire extinguisher training upon employment in personnel record # 3 and 6.
Employee # 3 was hired on 10/13/14 as a clinical supervisor. Employee # 3 completed the fire extinguisher training on 11/12/14.
Employee # 6 was hired on 2/3/14 as a counselor. Employee # 6 completed the fire extinguisher training on 3/28/14.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The ADAPPT training coordinator shall ensure that the designated fire safety trainer and Deputy Director are notified by phone or email upon the arrival of all new staff to ensure fire extinguisher training is scheduled and occurs within five days of employment.
The Deputy Director working in tandem with the Training Coordinator shall recieve notification of new hires on a weekly basis. The training Coordinater shall provide the Deputy Director with a list of scheduled times and dates for timely trainings. |
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.
|
Observations
Based on a review of administrative documentation, the project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's administrative records were reviewed for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services on 1/5/15. The facility's fiscal year runs from January 1 to December 31.
The facility did not complete an independent financial audit for the 2013 fiscal year.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for noncompliance of this standard during the 2/10/14 licensing inspection and the 8/22/14 follow up inspection.
|
Plan of Correction
The 2013 and 2014 financial audit will be completed by June 30, 2015. Moving forward, our CFO and our controller will ensure that a financial audit is scheduled immediately following the end of the fiscal year and that an annual financial audit will be completed by June 30 of every year. Furthermore, our Project Director will follow up with the controller with regards to the status of the audit by February and May of every year to ensure that it is scheduled and completed in a timely manner. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the frequency of treatment services on the individual treatment and rehabilitation plan in seven of ten client records reviewed.
The findings include:
Ten client records requiring documentation of the frequency of treatment services on the individual treatment and rehabilitation plans were reviewed during the renewal inspection. The individual treatment and rehabilitation plans contained in client records # 1, 2, 5, 6, 8, 9 and 10 did not include the frequency of treatment services.
Client # 1 was admitted to treatment on 9/25/14. The client's individual treatment and rehabilitation plan dated 10/9/14 did not specify the frequency of individual counseling therapy.
Client # 2 was admitted to treatment on 10/18/14. The client's individual treatment and rehabilitation plan dated 10/28/14 did not specify the frequency of individual counseling therapy.
Client # 5 was admitted to treatment on 9/16/14. The client's individual treatment and rehabilitation plan dated 9/30/14 did not specify the frequency of individual counseling therapy.
Client # 6 was admitted to treatment on 9/6/14. The client's individual treatment and rehabilitation plans dated 9/25/14, 10/7/14 and 10/16/14 did not specify the frequency of individual counseling therapy.
Client # 8 was admitted to treatment on 11/4/14. The client's individual treatment and rehabilitation plans dated 12/2/14 and 12/30/14 did not specify the frequency of individual counseling therapy.
Client # 9 was admitted to treatment on 11/4/14. The client's individual treatment and rehabilitation plans dated 12/15/14 and 12/30/14 did not specify the frequency of individual counseling therapy.
Client # 10 was admitted to treatment on 11/13/14. The client's individual treatment and rehabilitation plan dated 12/16/14 did not specify the frequency of individual counseling therapy.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The deficiencies were discussed with clinical staff during a clinical staff meeting held in the Clinical Supervisor's office. The following plan of correction was developed. Individual treatment and rehabilitaion plans shall at all times include the frequency of treatment services. The Clinical Supervisor shall ensure that all charts are reviewed and signed at least every 30 days to ensure all paperwork is in client charts and the chart is complete. His/her signature will confirm that the chart has been reviewed. |
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:
|
Observations
Based on the review of client records, the facility failed to ensure that a complete record was documented in eight of ten client records reviewed.
The findings include:
Ten client records were reviewed for documentation of a complete client record during the renewal inspection on 1/5/15 through 1/6/15. The facility failed to document a complete record in client records # 1, 4, 5, 6, 7, 8, 9 and 10.
Client # 1 was admitted on 9/25/14 and discharged on 11/9/14. The record of service for the client did not include the individual counseling session that the client attended on 10/30/14.
Client # 4 was admitted on 9/26/14 and discharged on 12/27/14. The record of service for the client indicated that the client attended a group counseling sessions on 11/11/14, 11/12/14, 11/13/14, 11/18/14, 11/19/14 and 11/20/14. No progress notes were documented in the client's record for these group counseling sessions.
Client # 5 was admitted on 9/16/14 and discharged on 11/17/14. The record of service for the client indicated that the client attended a group counseling session on 11/12/14. A progress note was not documented in the client's record for this group counseling session.
Client # 6 was admitted on 9/6/14 and discharged on 11/3/14. The record of service for the client indicated that the client attended an individual counseling session on 10/15/14. A progress note was not documented in the client's record for this individual counseling session.
Client # 7 was admitted on 9/24/14 and discharged on 11/13/14. The record of service for the client did not include the group counseling session that the client attended on 11/13/14.
Client # 8 was admitted on 11/14/14 and was still an active client at the time of inspection. A record of service for November 2014, December 2014 and January 2015 was not documented in the client's record.
Client # 9 was admitted on 11/4/14 and was still an active client at the time of inspection. A record of service for November 2014, December 2014 and January 2015 was not documented in the client's record.
Client # 10 was admitted on 11/13/14 and was still an active client at the time of inspection. A record of service for November 2014, December 2014 and January 2015 was not documented in the client's record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for noncompliance of this standard during the 3/11/14 supervisory review of the 2/10/14 licensing inspection and the 8/22/14 follow up inspection.
|
Plan of Correction
There shall be a chronological listing (separate from the progress notes) of the various specific services provided to the individual client, e.g. individual and group sessions. The listing will include the date of service, the duration of service, the service provided and the signature of the provider and client. The record of service sahll be found at all times within the client file and be accurate to the day.
Training for all counselors on the proper protocol to be followed related to client files shall be presented by the Clinical Supervisor, and shall include an emphasis on a daily and accurate client record of service.
Going forward, Counselors shall submit to the Clinical Supervisor client files for auditig on a weekly basis to ensure that file informatin is complete. Paperwork not deemed correct by the Clinical Supervisor shall be returned to the counselor for corrections and expected to be re-submitted within 48 hours. |