INITIAL COMMENTS
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This report is a result of an on-site renewal inspection conducted on licensure May 30, 2007 to May 31, 2007 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on June 25, 2007.
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Plan of Correction
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705.28 (b) (2) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(2) Place the smoke detector in a common area or hallway. All detection devices shall be interconnected.
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Observations
The facility failed to have interconnected smoke detectors between their two floors.
Facilities occupying multiple floors must have the detection devices installed so that all devices sound an alarm when one device is activated.
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Plan of Correction
Standard(s) in Non-Compliance: 705.28 Fire safety. (b)Smoke detectors and fire alarms. The nonresidential facility shall: (2) Place the smoke detector in a common area or hallway. All detection devices shall be interconnected.
Explanation: The facility failed to have interconnected smoke detectors between their two floors. Facilities occupying multiple floors must have the detection devices installed so that all devices sound an alarm when one device is activated.
Proposed Timeframe for Achieving Compliance: Immediately. At the request of TWP, Bitner Electric made a site visit on 6/14/07 to inspect fire detection system. At that time, we were informed our system had been interconnected since their visit of April 24, 2007. He demonstrated had to activate a single device as well as activating the whole system. Accordingly, we are in compliance with this standard.
Methodology for Achieving and Maintaining Compliance: Individual devices will be checked at each monthly fire drill. The system will be checked at each monthly fire drill.
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705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
The facility failed to request and receive an alternative procedure for conducting fire drills with verbal alerts.
A fire alarm or smoke detector must be activated during each drill unless the Department has approved an alternative procedure in writing.
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Plan of Correction
Proposed Timeframe for Achieving Compliance: Immediately. On 6/14/07, we conducted the June 2007 monthly fire drill using our interconnected smoke detector system. All future monthly fire drills will be conducted in the same manner.
Methodology for Achieving and Maintaining Compliance: Record of the use of the interconnected smoke detector system will be recorded in the monthly fire log.
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709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
The facility failed to document support services within the comprehensive treatment plan in 1 of 2 records reviewed. (Client record #1)
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Plan of Correction
Proposed Timeframe for Achieving Compliance: Immediately. On 6/8/07 during supervision, Facility Director and therapist reviewed chart in noncompliance. Therapist committed to identifying support services with client in next scheduled session (6/8/07) and recording such. Therapist recommitted to following through with identifying and recording any and all support services during the session the comprehensive treatment is written with the client (that is, the 4th session).
Methodology for Achieving and Maintaining Compliance: The Facility Director and the Physician signing the comprehensive treatment plan will ensure that the client's support services (as well as all other required treatment plan areas) are documented accordingly.
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709.94(g) LICENSURE Project management services
709.94. Project management services.
(g) Outpatient projects which receive reimbursement under the medical assistance program shall have a current, signed provider agreement with the Department of Public Welfare and comply with 55 Pa. Code Part III (relating to Medical Assistance Manual).
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Observations
The facility failed to have the physicians' review and sign-off on the comprehensive treatment plans.
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Plan of Correction
Proposed Timeframe for Achieving Compliance: Immediately. On 6/8/07 policy and procedures 709.92 (a) and 709.92(b) were revised to include the physician's signature and the accompanying client forms were revised to include a space for the physicians dated signature. On 6/11/07 a copy of the pre-existing Pennsylvania DPW Certificate of Compliance with a copy of the signed Pennsylvania DPW Provider Agreement for Outpatient Providers was faxed to the licensing inspectors.
Methodology for Achieving and Maintaining Compliance: On 6/8/07 at supervision, Facility Director reviewed the revised P&P's and modified client forms with the therapists and psychiatrists. On June 11, 2007 a MEMO regarding the aforementioned was circulated and the revised P&P's and modified client forms replaced the previously existing incorrect forms. The psychiatrists will review and sign all future comprehensive master treatment plans and treatment plan updates.
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