INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 26, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, BI Incorporated 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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705.2 (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.
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Observations
Based on a physical plant inspection, the residential facility failed to 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 findings include:
A physical plant inspection was conducted on December 26, 2012. During the inspection, the front door to the facility was inoperable. The door was stuck and could not be opened from the outside in order to gain entry to the facility.
The findings were discussed with the facility director and were not disputed.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on observation the facility failed to have cold water under pressure during the physical plant inspection.
The findings include:
The physical plant inspection took place on December 26, 2012. The cold water was tested in the bathroom designated for staff use and there was no cold water.
The facility director confirmed that there was no cold water under pressure in the staff bathroom.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the fire drill logs the facility failed to document the number of staff and clients present during the fire drill.
The findings include:
Fire drill logs were reviewed on December 26, 2012. Per regulation, the nonresidential facility shall maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. The facility failed to document the number of staff and clients present during all fire drills conducted.
On December 26, 2012 the project/facility director was interviewed and confirmed that the number of staff and clients present during the fire drill was not documented for any of the fire drills conducted.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors in three of five client records.
The findings include:
Five client records were reviewed on December 26, 2012. A psychosocial evaluation was required in five of those records.
Client records #1, 3, 4, and 5 lacked an assessment of the client's composite picture and how it would impact treatment.
Client records #1, 3, 4, and 5 lacked an assessment of the client's problems and needs and how they would relate to treatment.
Client records #1, 3, and 5 lacked an assessment of the client's assets and strengths and how they would relate to treatment.
Client records #3, 4, and 5 lacked an assessment of the client's coping mechanisms and how they would relate to or impact treatment.
Client records #1, 3, 4, and 5 lacked an assessment of the client's negative factors and how they would impact treatment.
Client records #1, 2, 3, 4, and 5 lacked an assessment of the client's attitude toward treatment and how it would impact treatment.
Client records #1, 2, 3, 4, and 5 lacked an assessment of the counselor conclusions and impressions and how it would impact treatment.
This finding was discussed with the Facility Director who did not dispute the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |