INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on Aug 3, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Project Transition- Andorra was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
The Staffing Requirements Facility Summary Reports for the 5 facilities were reviewed on August 2, 2016. Based on this review, the facility failed to have a full-time clinical supervisor for every eight full-time counselors and/or counselor assistants.
The equivalent of 8 full-time counselors were employed within the project requiring at least 1 full-time clinical supervisor. The project did not have a full-time clinical supervisor employed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This finding was presented to the facility on 11/4/16 and reviewed with the Project Director. Based on the review of these findings and a review of our staffing model against DDAP Regulations, we have designated 1 full-time Clinical Supervisor positions filled by Dr. Terry Murphy. These will be full time position, will not carry any direct case loads and will provide the direct supervision over the counselors. To prevent this issue from occurring in the future, the project director will monitor the formula for calculating how many FTE counselors are in the project and the project director will ensure that the project employs the required number of clinical supervisors based on the results of these calculations. |
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
A physical plant inspection was conducted on August 3, 2016. The facility failed to ensure that the hot water temperature did not exceed 120 During the inspection, the water temperatures were tested in the two bathrooms and both resulted in a temperature reading of 125 findings were confirmed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director. Based on the review of these findings our Facilities Manager has double checked all bathroom hot water temperatures in this facility as well as all other Project Transition facilities and lowered the hot water heater temperature gauge for any recordings over 120 degrees as of August 19, 2016. To prevent this issue from occurring in the future, the Director of Facilities Management will ensure bathroom hot water temperatures heaters are kept at a lower temperature in all facilities and he will monitored the water temperatures more thoroughly with findings recorded on a quarterly basis. The Director of Facilities Management will document a water temperature above 118 degrees as part of the Office Safety Checklist and will immediately work to ensure the temperature is correct. This quality check process will begin with the next quarterly review for each location, scheduled to be completed by September 30th. In addition, any corrective action necessary due to out of range water temperature will be reported to the Director of Business Operations through the supervision process. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
A physical plant inspection was conducted on August 3, 2016. The facility failed to ventilate each bathroom by either an exhaust fan or window.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director. Based on the review of these findings our Director of Facilities Management contacted the property management office for this facility on August 18, 2016 to report the requirement to install exhaust fans and properly ventilate each bathroom in the facility in accordance with PA code 41.32 h. The Property Management stated that the fans will be installed in both bathrooms by September 16, 2016. To prevent this issue from occurring in the future, the Director of Facilities has confirmed with the facility Property Management that the facility meets all required building codes. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
A review of client records was conducted on August 3, 2016. Based on this review, the facility failed to offer a copy of a client consent to the client.
Client # 5 was admitted on March 19, 2014 and discharged on March 17, 2016. On March 18, 2015 the client signed consents for an emergency contact, a funding source, and a pharmacy where acceptance or rejection of a copy was not documented. On July 27, 2015 the client signed a consent for a leasing office where acceptance or rejection of a copy was not documented.
These findings were confirmed with facility staff during the licensing process.
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Plan of Correction
These findings were reviewed with the Project Director. Based on the review of these findings the Facility Director will ensure a full review of all active members consents forms will be completed and a copy of the consent was provided to Members if they record does not indicate a copy was provided by 8/30/16. To prevent this issue from occurring in the future, the Facility Director has changed the consent form process to always provide a copy of all signed consents to the Member regardless of desire to accept or reject the copy after receipt. This updated process will be implemented on 9/1/16. |