INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 15, 2014 - January 16, 2014 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, Drug & Alcohol Treatment Services 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential 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 clients, 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 observation during the physical plant inspection, the 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 with the Project Director on January 15, 2014. During the inspection, the facility's rear parking lot was observed to have potholes, cracks, and divots throughout the entire lot. There also were areeas of the parking lot that had
The Project Director did not dispute the findings.
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Plan of Correction
As per a plan set forth last year the parking lot was suppossed to be completely redone by August of 2013. Proceeds from the Agency Annual Golf Tournamnet (fundraiser held annually in June)) were to be used. Unfortunatley a large portion of the HVAC system had to be replaced thus using the available finances.
The same plan will be followed again this year with a target date for completion of July 1, 2014. The process will be scheduled and overseen by the Agency Operations Manager. |
709.83(a) LICENSURE Client records
709.83. 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 provide a complete client record on an individual which includes information relative to the client's involvement with the project in two of the ten records reviewed in the partial hospitalization activity.
The findings include:
Ten client records were reviewed on January 15, 2014 to ensure that the facility maintained a complete client record for each client.
Client #7 was admitted to the partial hospitalization activity on 8-20-2012, then was subsequently transferred to the Outpatient activity and successfully discharged on 4-1-2013. The follow-up information in the client record lacked a date to verify when it had been completed.
Client #8 was admitted to the partial hospitalization activity on 5-16-13, then was subsequently transferred to the Outpatient activity and successfully discharged on 10-3-13. The client record was missing documentation of an aftercare plan.
The Project Director did not dispute the findings.
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Plan of Correction
As per 709.83 (a) (11) Follow-up Information a traing will be held with all clinical staff on February 6, 2014. The Clinical Supervisory Staff will conduct the training not only addressing the cited areas but will address the follow-up process as outlined in the licensing regulations as a whole.
The process will be overseen by the Executive Director. |