INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Jefferson Outreach Drug and Alcohol Program Central 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of twelve fire drill logs, the facility failed to conduct unannounced fire drills at least once a month. There were no unannounced fire drills conducted from April 2020 until time of the inspection due to the facility teleworking.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
It shall be the responsibility of the Facility Director to ensure that unannounced fire drills are conducted and logged on a monthly basis. However, the Facility Director will submit an exemption request to halt fire drills while the facility staff remain on a mandated telework schedule |
711.93(a)(7) LICENSURE Follow-up Information
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(7) Follow-up information.
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Observations
Based on a review of seven client records, the facility failed to ensure that client records contained follow up information in two of three applicable client records reviewed.Client #5 was admitted on August 30, 2019 and discharged on January 16, 2020. There was no documentation of follow up information in the client record. Client #6 was admitted on August 29, 2019 and was discharged on April 3, 2020. There was no documentation of follow up information in the client record.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
It shall be the responsibility of the Facility Director to ensure that follow up procedures are conducted with clients who are discharged from the program and who do not pose behavioral concerns that would prohibit them being readmitted to the program. The Facility Director will instruct the counselor to ensure that efforts to reach patients are documented either by including copies of the completed follow-up forms in the patient's chart or documenting unsuccessful follow up efforts in the progress notes section of the chart. |