INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on April 3, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Positive Pathways 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
|
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
The facility failed to ensure that the fan in the facility bathroom is in working order.
A physical plant walk through was completed on April 3, 2019. The 1st floor bathroom had an inoperable fan.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
705.6 Bathrooms Corrective Action Plan: Positive Pathways has contracted with an electrician to repair the exhaust fan in the first floor bathroom to ensure proper functioning that will satisfy regulation 705.6. The repair has been completed as of 5/3/2019. The ensure future compliance, the bathroom fans will be checked by the office manager at each location and the results documented on a monthly basis. Any malfunctions will be immediately reported to the facility director and repaired within five business days. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
The project failed to obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The facility's administrative records were reviewed on April 1-2, 2019 for documentation of an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year runs from July 1 to June 30. The project did not document an independent financial audit for the 2017/2018 fiscal year.
The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
709.25 Fiscal Management: Corrective Action Plan In response to the Fiscal Management deficiency in section 709.25. Positive Pathways has obtained the services of an independent accountant on April 19, 2019 for the future purpose of an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities. The annual audit will be completed within six months following the end of Positive Pathways' fiscal year. The project director will be directly responsible for completion of the task. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
|
Observations
The facility failed to provide written documention that the client was notified of the rights in one of one client records.
One client record was reviewed on April 3, 2019. One required documentation the client was informed of the rights.
Client record # 1 did not document that the client was informed of the rights.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
On 5/1/2019, Positive Pathways revised and implemented changes to correct the deficiency related to client rights. Client rights are documented in the client handbook. As of 5/1/2019, clients will sign-off on a signature page indicating they have received the client handbook and been informed of their client rights. The signature page will be scanned into the client's EMR chart. The clinical supervisor is responsible for compliance to the corrected plan of action. This will be reflected in the clinical supervisor's monthly chart audit results. Deficiencies discovered in the monthly chart audits will be addressed with the Program Director, with the counselor/staff person in question, and in the weekly staff meeting to help educate all others related to proper policy adherence. |