INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 7-8, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, 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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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on an inspection of the physical plant, the facility failed to provide slip resistant surfaces in all of the showers.The findings include:A physical plant inspection was conducted on July 8, 2014. During the physical plant inspection, it was noted that none of the showers in the client bathrooms were equipped with slip resistant flooring. The findings were reviewed with administrative and maintenance staff throughout the inspection and during the exit interview. Though the building supervisor insisted that textured tiles were used to provide a slip-resistant surface and would not confirm the finding, direct contact with the tiles revealed that there were no slip-resistant qualities at the time of inspection.
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Plan of Correction
The Director of Building Maintenance has to replace the tile in two of the client bathrooms due to a problem with the flooring underneath. He will be replacing the tile with slip- resistant tiles. The remainder of the bathrooms he will be placing slip- resistant strips across the existing tiles.
The Director of Building Maintenance is waiting for the commercial grade slip-resistant strips to come in. As soon as the shipment comes in (should be by August 21st) he will place the strips on the floor immediately.
In the meantime, all clients are provided with shower shoes to prevent them from slipping on the existing flooring.
The two bathrooms that need the tile replaced will have the strips placed on the tiles until the bathroom is closed to fix the entire floor and should be completed by September 30, 2014. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the fire drill log, the residential facility failed to conduct a fire drill during sleeping hours at least once every six months and to conduct drills during different shifts.The findings include:The facility's fire drill logs were reviewed on July 7, 2014. The fire drill logs were reviewed from the last survey, August 2013 to June 2014. The last documented fire drill during sleeping hours was conducted on November 14, 2013. Another sleeping hours drill should have been conducted in May 2014. Additionally, out of the fourteen drills that were conducted during this time period, eleven of them were between 7am - 3pm. This was discussed with and confirmed by the TLF Director.
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Plan of Correction
On August 11, 2014, the Director of Building Maintenance met with overnight staff again to instruct them on how to run fire drills during sleeping hours at least every six months. An overnight fire drill is to take place on or before August 30, 2014.
The Director of Building Maintenance shall check the fire drill logs on a monthly basis to ensure that fire drills are conducted during different shifts at least once every six months. |
709.22(e)(2) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(2) A financial statement of income and expenses.
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Observations
Based on a review of administrative documentation and an interview with the Director of Administration, the governing body failed to make available to the public an annual report which included a statement of the project's income and expenses for the preceding year.The findings include:The facility's administrative documentation was reviewed on July 7, 2014. The annual report did not include a financial statement. The findings were confirmed with the Director of Administration who believed that showing the fiscal audit would meet the requirements.
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Plan of Correction
The Director of Administration will ensure that before the annual report is posted on Self Help Movement's website, that it does include a statement showing the facility's income and expenses for the preceding year.
The Director of Administration will place a modified annual report for 2014 on the website showing fiscal year 2013's income and expenses.
This will be accomplished by September 30, 2014. |
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 a review of client records, the facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project regarding verification of work therapy in the comprehensive treatment plan and/or treatment plan update in ten out of ten records reviewed.The findings include:Ten client records requiring documentation of a complete client record on an individual which includes information relative to the client's involvement with the project were reviewed on July 7-8, 2014. Each of the records reviewed included documentation that the clients were doing work tasks around the facility, exclusive of their immediate living space. The facility did not document verification of work therapy in the comprehensive treatment plan and/or treatment plan update in ten of ten records reviewed, specifically, client records # 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.The comprehensive treatment plan for client # 1 was completed on March 20, 2014. The facility was required to document work therapy in the comprehensive treatment plan; however there was no documentation of work therapy in the comprehensive treatment plan. The comprehensive treatment plan for client # 2 was completed on March 23, 2014. The facility was required to document work therapy in the comprehensive treatment plan; however there was no documentation of work therapy in the comprehensive treatment plan. The comprehensive treatment plan for client # 3 was completed on February 20, 2014. The facility was required to document work therapy in the comprehensive treatment plan; however there was no documentation of work therapy in the comprehensive treatment plan. The comprehensive treatment plan for client # 4 was completed on November 24, 2013. The facility was required to document work therapy in the comprehensive treatment plan; however there was no documentation of work therapy in the comprehensive treatment plan. The comprehensive treatment plan for client # 5 was completed on December 24, 2013. The facility was required to document work therapy in the comprehensive treatment plan; however there was no documentation of work therapy in the comprehensive treatment plan. The comprehensive treatment plan for client # 6 was completed on November 4, 2013. The facility was required to document work therapy in the comprehensive treatment plan; however there was no documentation of work therapy in the comprehensive treatment plan. The comprehensive treatment plan for client # 7 was completed on June 21, 2014. The facility was required to document work therapy in the comprehensive treatment plan; however there was no documentation of work therapy in the comprehensive treatment plan. The comprehensive treatment plan for client # 8 was completed on June 1, 2014. The facility was required to document work therapy in the comprehensive treatment plan; however there was no documentation of work therapy in the comprehensive treatment plan. The comprehensive treatment plan for client #9 was completed on June 2, 2014. The facility was required to document work therapy in the comprehensive treatment plan; however there was no documentation of work therapy in the comprehensive treatment plan. The comprehensive treatment plan for client # 10 was completed on May 9, 2014. The facility was required to document work therapy in the comprehensive treatment plan; however there was no documentation of work therapy in the comprehensive treatment plan. This was previously cited during the August 23, 2013 inspection. The finding were confirmed with the clinical director.
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Plan of Correction
On July 9, 2014, The Clinical Director conducted a training with the counselors to ensure that, when appropriate, the comprehensive treatment plan and/or treatment plan will include information regarding a client's involvement in work therapy.
The Clinical Director, when checking the client charts, will make sure that if the client was involved in work therapy that it is documented in the comprehensive treatment plan. |