INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Detox Unit 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 and a plan of correction is due on February 12, 2008.
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Plan of Correction
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection on January 11, 2008, the facility failed to provide a permanently mounted or installed heater in the two physician offices located at the end of the building. The physician's office utilized by the Licensing Specialist on January 11, 2008 contained a free-standing space heater. It was reported by the Director of Nursing that there is no heat available for the two end offices on the detoxification unit.
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Plan of Correction
The issue of heat in rm 133 of the Medical Unit was an oversight on the part of the Director of Plant Operations.
We will be adding a fixed source of heat to room and this will be completed by April 25th 2008.
The equipment will be ordered by 2/15/08 by the Supervisor of Maintenance. The Director of Plant Operations will verify on 2/15/08 that the equipment has been ordered.
Upon receipt of the equipment, a technician will be assigned to install the equipment. The Supervisor of Maintenance will be in charge of the assignment.
This will be completed within 5 days after the project has started. The Director of Plant Operations will verify completion by 5 days after the project is scheduled.
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709.62(c)(vi) LICENSURE Psychosocial Eval
709.62. Intake and admission.
(c) Intake procedures shall include documentation of the following:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records on January 11, 2008, the facility failed to document a complete psychosocial evaluation in three of three client records reviewed, #1, 2 and 3. Psychosocial evaluations completed by nursing staff did not provide an assessment of the client's past and present circumstances, but rather consisted of two to three sentences regarding the client's demographics.
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Plan of Correction
The corrective action includes a revision to the Nursing Admission Summary that includes affect, suicide assessment, SIB assessment, abuse history, eating disorder issues identified, psychiatric issues, medical issues and urgent patient needs. This revision to the document will be completed by the Director of Nursing with training to staff by 4/1/08. Ongoing compliance will be insured with chart audits monthly for a minimum of 6 months. Review of results by the DON with corrective action through supervision. |