INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on September 22, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Spring-Ford Counseling Services, Inc. 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.
|
Plan of Correction
|
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.
|
Observations
Based on a 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:
An inspection of the facility's physical plant was conducted on September 22, 2011 between approximately 9:30 AM and 10:00 AM. At the time of inspection, the grounds of the facility were not in good repair.
Ceiling tiles in two counseling offices were stained.
Ceiling tiles in conference room were stained and some of the ceiling tiles were also missing.
The findings were confirmed by the facility director on September 22, 2011.
|
Plan of Correction
Within 60 days, Program Director inconjuction with Building Landlord will replace all stained ceiling tiles in both counseling offices and replace missing tiles in the conference room. Building Landlord has already been notified and visually inspected the site. The Program Director will visually inspect ceiling in all offices every quarter. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on the review of client records, the facility failed to document treatment plan updates to include an assessment of the client's progress in one of two records.
The findings include:
On September 22, 2011, treatment plans updates in two client records were reviewed, specifically records # 3 and 4. The facility did not document treatment plan updates to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan in record # 3.
Client # 3 was admitted on 6/16/11. The treatment plan update in client record # 3 dated 8/4/11 did not include an assessment of the client's progress.
An interview with the facility director on September 22, 2011 confirmed the findings.
|
Plan of Correction
Within 30 days, Program Director will notify staff that treatment plan updates should include assessment of the client's progress in relationship with stated goals. Program Director shall modify treatment plan update to indicate "assessment of client's progress". Program Director shall review all charts to ensure compliance with this citation. |