INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the April 16, 2009 licensure renewal inspection. The follow-up inspection was conducted on August 17, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Colonial 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 and a plan of correction is due on September 7, 2009.
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Plan of Correction
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705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on the physical plant and interview with facility director, the facility failed to maintain a minimum of two exits on every floor.
The findings include:
The physical plant follow up inspection and interview with the facility director was conducted on August 17, 2009. The second floor office area only has one exit.
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Plan of Correction
Construction of the fire escape (second floor exit) is under construction. It began today, August 31st, 2009 and will be done by September 4th, 2009. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document complete case consultations notes in six of eight client records.
Findings:
Eight client records were reviewed on August 17, 2009. Case consultations were required in eight client records. In accordance with the facility's policy and procedure case consultation notes will be documented every 90 days after admission. Client record #1 was admitted on 5/7/09 and as of to date no case consultation has been documented. Client record #4 was admitted on 4/27/09 and as of to date no case consultation has been documented. Client record #6 was admitted on 9/23/08 and as of to date no case consultation has been documented. Client record #8 was admitted on 4/7/09 and as of to date no case consultation has been documented. Client record #5 was admitted on 3/27/09 and his case consultation was done on 8/6/09, but should have been done on 6/27/09. Client record #7 was admitted on 1/30/09 and last case consultation was done 4/23/09 the next one should have been done by 7/23/09 and as of to date this was not documented in record.
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Plan of Correction
Counselors have been given policy and reglations regarding case consultations and it has been reviewed with the staff. During weekly staff meetings counsleors will be bringing current charts to be reviewed. For contractual part time staff there will also be a weekly staff meeting. This will be the responsibilty of the director. |