INITIAL COMMENTS
|
This report is a result of a complaint investigation conducted on August 31, 2017, by staff from the Program Licensure Division. Based on the findings of the complaint investigation, the allegations made against Alpine Springs Rehabilitation & Recovery were partially substantiated and Alpine Springs Rehabilitation & Recovery 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 complaint investigation:
|
Plan of Correction
|
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
|
Observations
The facility failed to ensure exits were unobstructed. The second exit from the detoxification area was not operable at all times.
This was confirmed during a follow-up conversation with the facility staff.
|
Plan of Correction
Fire exit our of detox will have an Emergency Exit only sign posted on it. There are no valuables in the front office or any client information that could compromise confidentiality or HIPPA laws. The door will remain unlocked and the exit unobstructed, Sign will be posted by 10/11/2017, this will be monitored by the Executive Director |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
|
Observations
The facility failed to document that all staff were trained in the use of fire extinguishers upon staff employment.
Personnel records were reviewed on August 31, 2017. None of the current employees had documentation of fire extinguisher training.
These findings were reviewed with the facility staff.
|
Plan of Correction
All new hire staff will be trained with in the first week of hire on fire extinguisher use. training will be done by designated fire safety staff person, and monitored by the Executive Director. All staff that have not had training will be trained in fire extinguisher use by fire safety staff person by 9/30/2017. This will be monitored by the Executive Director. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
The facility failed to conduct unannounced fire drills at least once a month.
The last licensing inspection was in November 2016. Fire drills were not conducted between November 2016 and June 2017.
These findings were reviewed with the facility staff.
|
Plan of Correction
Fire safety staff person has been assigned to be in charge of fire of drills and will ensure they are done on a monthly basis. Executive director and Fire safety staff person will meet on a monthly basis to review fire drill procedures and make improvements as necessary. This will be implemented on 10/11/2017 |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
|
Observations
The facility failed to document and file a written unusual incident report with the Department for unusual incidents that occurred in the facility.
Facility documentation was reviewed on August 31, 2017 and there were multiple incidents that have occurred onsite that would require a written unusual incident report to be documented and provided to the Department. There were no unusual incidents documented and filed with the Department.
These findings were reviewed with the facility staff.
|
Plan of Correction
All unusual incidents will be reported to DDAP on the Unusual Incident report form and those meeting criteria will be reported within 48 hours via phone. Unusual incident forms will be filed and kept in the Executive Directors office. This policy was implemented on 10/11/2017 and will be followed and completed by the Executive Director. |