INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 22, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment, 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 and a plan of correction is due on October 22, 2010.
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Plan of Correction
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705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection and an interview with the clinical supervisor, the facility failed to ventilate the client bathroom by an exhaust fan or window.
The findings include:
A physical plant inspection was conducted with the clinical supervisor on September 22, 2010 at 9:45 AM. Per regulation, the nonresidential facility shall ventilate bathrooms by exhaust fan or window. The facility has one bathroom designated for clients. The bathroom is located in a hallway and does not have any windows. There is an exhaust fan in the bathroom which is no longer operative. The clinical supervisor confirmed the exhaust fan in the bathroom was not operative at the time of the inspection.
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Plan of Correction
The facilities maintenance staff have repaired the broken bathroom exhaust fan. The repair took place immediatley after the broken exhaust fan was identified. The exhaust fan is currently operational. The Clinical Supervisor and our Facilities Manager shall perform inspection at least weekly to ensure that all physical plant standards are adhered too and there are no safety or sanitation violations. Staff shall recieve instruction on the importance of physical plant standards and shall be instructed to report violations immediatley. Any violations shall be reported to the maintenance staff for immediate correction. This plan of correction is currently in place. The Clinical Supervisor shall provide oversight and ensure compliance with this plan of correction. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill logs were reviewed on September 28, 2010 for the period of March - September 2010. Per regulation, the nonresidential facility shall prepare alternate exit routes to be used during fire drills. The facility did not document any alternate exits used during fire drills. The front door was the exit route used during every fire drill.
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Plan of Correction
The Clinical Supervisor provided the staff with training on the importance of using alternating fire exits at least every other month over the course of the year. The Clinical Supervisor and staff will use both exits simultaneously during each monthly drill or will ensure that both routes are used at least every other month. The Clinical Supervisor and Project Director shall ensure that this takes place and is clearly documented on the fire drill form. This plan of correction is in place. The Project Director and Clinical Supervisor shall provide appropriate oversight and shall review the fire drill logs to ensure compliance with this plan of correction. |
709.24(a)(3) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of policies, procedures, client records and an interviews with the clinical supervisor and counselor, the facility failed to comply with it's own written policy of obtaining client histories at intake.
The findings include:
The project policy and procedure manual was reviewed on September 21, 2010. The project policy states that client histories will be completed at intake for all clients. Ten outpatient client records were reviewed on September 22, 2010. All ten client records required client histories completed during intake. Client records # 1, 3, 4, 5, 7, 9 and 10 contained client histories that were completed after the intake period.
Client # 1 had an intake period ending on May 17, 2010. The client histories were completed on May 28, 2010.
Client # 3 had an intake period ending on June 22, 2010. The client histories were completed on August 3, 2010.
Client # 4 had an intake period ending on June 2, 2010. The client histories were completed on June 9, 2010.
Client # 5 had an intake period ending on March 1, 2010. The client histories were completed on March 11, 2010.
Client # 7 had an intake period ending on May 5, 2010. The client histories were completed on May 19, 2010.
Client # 9 had an intake period ending on March 18, 2010. The client histories were completed on March 25, 2010.
Client # 10 had an intake period ending on April 26, 2010. The client histories were completed on May 6, 2010.
An interview with the clinical supervisor and counselor took place on September 22, 2010 at which time the above information was confirmed. It was explained to the licensing specialist that the counselors often require several sessions to complete all of the intake paperwork and obtain client histories.
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Plan of Correction
Renewal Treatment Inc. has changed our written policy and no longer requires obtaining client histories during intake. The policy has been changed to require client histories to be completed by the client's 3rd session and requiring a time frame of no longer than 3 weeks from their initial intake appointment. The treatment staff have recieved training on this new policy and are adhering to this directive. This plan of correction is in place. The Project Director and Clinical Supervisor shall ensure compliance and oversight of this plan of correction. |