INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Roxbury 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 maintain a written fire drill log which included 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 findings include:
The facility fire drill logs from March 2013-January 2014 were reviewed for compliance on January 21, 2014. The fire drill logs failed to include documentation of the exit route used during the fire drill.
The Project Director confirmed the findings.
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Plan of Correction
The Director of Plant Operations is responsible for modification of the fire drill log to include the exit route used. The modification of the form was completed during the time of survey. Compliance with the fire drill log documentation will be monitored monthly by the Director of Plant Operations and will be reported in the Environment of Care Committee meeting monthly for a period of 4 months. |
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 provide a complete client record which included follow-up information and a case consultation in three of six records reviewed.
The findings include:
Six client records which required documentation of follow-up information and case consultation notes were reviewed January 21-22, 2014. The facility failed to document follow-up information in client record # 3 and a case consultation in client records # 2 & 4.
Client # 2 was admitted on 8/30/13 and was discharged on 9/23/13. This client record failed to include documentation of the completion of a case consultation.
Client # 3 was admitted on 7/19/13 and was discharged on 8/13/13. This client record failed to include documentation of follow-up which included the date the follow-up was completed.
Client # 4 was admitted on 8/28/13 and was discharged on 9/16/13. This client record failed to include documentation of the completion of a case consultation.
The Project Director confirmed the findings.
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Plan of Correction
Staff will be re-educated by the Clinical Supervisor on proper completion of case consults and documentation of follow-up on the Chemical Dependency Unit by March 17, 2014. The Clinical Supervisor will complete an audit of 20 charts monthly to ensure compliance and proper completion of case consults. The Clinical Supervisor will complete an audit for 20 patients in regards to aftercare follow-up to ensure proper documentation of completion of follow-up. The results will be discussed and monitored in Performance Improvement Meeting Monthly. The audit will continue for a period of four months. Target Date for completion: June 30, 2014. |