INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 19, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Providence Living LLC d/b/a Providence Living Treatment Center 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 the facility's fire drill log, the facility failed to conduct unannounced fire drills at least once a month. In addition the facility failed to set off a fire alarm or smoke detector during each fire drill.
The findings include:
The facility's fire drill log was reviewed on January 19, 2016 covering the period of June 2015 through January 2016. The facility failed to conduct an unannounced fire drill during the months of July 2015, September 2015, October 2015 and November 2015.
In addition the facility failed to set off a fire alarm or smoke detector during the fire drills for the month of August 2015, December 2015, and January 2016.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
Our facility director is responsible for ensuring below described plan of correction will be implemented.
1) Regarding the fire drill frequency, Providence Living Treatment Center is committed to conduct unannounced fire drill at least once a month, effective immediately. Furthermore, each fire drill will also be conducted on different day of the month at different time of the day during our business hours.
2) Regarding setting off fire alarm or smoke detector during each fire drill, our building is equipped with central fire protection system that includes inter-connected sprinkler heads, smoke detectors, pull station and fire strobes. We find it difficult to set off fire alarm or smoke detector during each fire drill without creating hardship to the rest of building tenants and having to evacuate everyone. Hence, we submitted a request for exception letter to the Director of Division of Drug and Alcohol Program Licensing on 1/28/16, requesting that we will perform monthly mock fire drill and we will obtain a copy of proof of annual testing to ensure that our building fire protection system is fully operational at all times.
Additionally, annual testing of our building's fire protection system will be performed by a qualified third-party fire company.
While the exception letter is being reviewed by DDAP, we will continue to follow the licensing regulations and ring a bell to simulate the fire alarm sounding during each monthly fire drill. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on the review of client records, the facility failed to document that an individual treatment and rehabilitation plan was developed with the client in seven of seven client records.
The findings include:
Seven client records were reviewed on January 19, 2016. The facilty failed to document that an individual treatment and rehabilitation plan was developed with the client in client records #1, 2, 3, 4, 5, 6 and 7.
Client #1 was admitted on December 28, 2015. The individual treatment and rehabilitation plan was completed on January 4, 2016; however the facility failed to verify that the treatment plan was developed with the client as the plan was not signed by the client.
Client #2 was admitted on December 28, 2015. The individual treatment and rehabilitation plan was completed on December 30, 2015; however the facility failed to verify that the treatment plan was developed with the client as the plan was not signed by the client.
Client #3 was admitted on January 6, 2016. The individual treatment and rehabilitation plan was completed on January 11, 2016; however the facility failed to verify that the treatment plan was developed with the client as the plan was not signed by the client.
Client #4 was admitted on December 21, 2015. The individual treatment and rehabilitation plan was completed on December 28, 2015; however the facility failed to verify that the treatment plan was developed with the client as the plan was not signed by the client.
Client #5 was admitted on July 29, 2015. The individual treatment and rehabilitation plan was completed on August 2, 2015; however the facility failed to verify that the treatment plan was developed with the client as the plan was not signed by the client.
Client #6 was admitted on August 25, 2015 and discharged on November 17, 2015. The individual treatment and rehabilitation plan was conducted on September 1, 2015; however the facility failed to verify that the treatment plan was developed with the client as the plan was not signed by the client.
Client #7 was admitted on November 13, 2015 and discharged on December 16, 2015. The individual treatment and rehabilitation plan was conducted on November 16, 2016; however the facility failed to verify that the treatment plan was developed with the client as the plan was not signed by the client.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
Our facility director is responsible for ensuring below described plan of correction will be implemented.
Effective immediately, all our current and future clients will be required to provide their signature on a master treatment plan cover sheet that says below:
"I hereby have read and understand the master treatment plan that was presented to me by my primary counselor at Providence Living Treatment Center and I agree to work toward my treatment goals as outlined in the plan."
________________________________________________
Please print name/signature
_______________________________________________
Date
This signed cover sheet will then be attached to our clients' master treatment plan in their individual clinical chart as permanent record.
Additionally, a monthly internal audit will be performed to ensure that this deficiency will not re-occur that master treatment plan will be signed by our clients. |