INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 12, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Psychological Services of York, LLC 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:
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Plan of Correction
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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Policy and procedure manual has been revised to include: a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. |
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 on October 12, 2022, the facility failed to ventilate bathrooms by exhaust fan or window.
The exhaust fan in the bathroom was not operable during the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fan in the bathroom is now operational. The program director is responsible for monitoring this and ensuring that the fan remains operational. The program director will enter the bathroom during each workday at the beginning of the day to verify that the fan is operational. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection on October 12, 2022, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
Both of the facility ' s fire extinguishers were last inspected in July 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire extinguishers have been inspected and are now up to date. The program director will monitor the fire extinguishers using a calendar reminder on an annual basis to ensure that the fire extinguishers are up to date for yearly inspections, which are arranged by the building management company. The program director will communicate with the building management as needed to ensure that the fire extinguishers are up to date. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of one personnel record, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment.
Employee #1 was hired as the Project Director/ Facility Director on January 25, 2022. There was not documentation of fire extinguisher training in the personnel record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon each staff person's hire date, the program director will schedule fire extinguisher training and ensure that the staff is trained on an annual basis thereafter. The program director will utilize an electronic data collection system in order to track staff fire extinguisher training and ensure that each staff member is current. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of administrative paperwork submitted by the facility, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of any unannounced fire drills being conducted since the facility opened.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Monthly fire drills will be conducted and documented in the fire drill log from this point forward. The program director will utilize an excel spreadsheet to keep a log of fire drills. Each fire drill will be logged on the spreadsheet, including the date of the drill, staff present, time of drill, exit path used, amount of time it took for all staff to fully evacuate, the number of persons present in the facility, problems encountered, and whether the smoke detectors were operational. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of administrative paperwork, the facility failed to maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill log has been modified and the following data will be collected on a monthly basis following monthly fire drills: written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative. |
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 the facility ' s policy and procedure manual, the facility failed to adopt a written plan for the coordination of client treatment and rehabilitation services which includes written procedures for the management of treatment/rehabilitation services for clients.
The written procedures submitted by the facility did not include the time frames for when the preliminary treatment plan, psychosocial evaluation, case consultations or discharge summary will be completed by.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised reflecting the following changes:
written plan for the coordination of client treatment and rehabilitation services which includes written procedures for the management of treatment/rehabilitation services for clients and the time frames for when the preliminary treatment plan, psychosocial evaluation, case consultations or discharge summary will be completed by. |
709.24 (a) (4) 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:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to adopt a written plan for the coordination of client treatment and rehabilitation services which includes written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
The written plan submitted by the facility did not include procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised reflecting a written plan for the coordination of client treatment and rehabilitation services which includes written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services and procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to a physical assault or sexual assault by staff or a client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect policies and procedures to respond to a physical assault or sexual assault by staff or a client. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to selling or use of illicit drugs on the premises.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect policies and procedures to respond to selling or use of illicit drugs on the premises. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to a death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect policies and procedures to respond to a death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to a significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect policies and procedures to a significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to a theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect policies and procedures to a theft, burglary, break-in or similar incident at the facility. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to an event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect policies and procedures to an event at the facility requiring the presence of police, fire or ambulance personnel. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to a fire or structural damage to the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect policies and procedures to a fire or structural damage to the facility. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect policies and procedures to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop policies and procedures related to reporting unusual incidents that included the implementation of a timely and appropriate corrective action plan, when indicated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect policies and procedures related to reporting unusual incidents that included the implementation of a timely and appropriate corrective action plan, when indicated. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop policies and procedures related to reporting unusual incidents that included the ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect policies and procedures related to reporting unusual incidents that included the ongoing monitoring of the corrective action plan. |
709.34 (b) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop policies and procedures related to reporting unusual incidents that included the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect policies and procedures related to reporting unusual incidents that included the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. |
709.94(f)(1) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(1) Identifying persons in need of project services.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop a written plan providing for outreach services that includes identifying persons in need of project services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect a written plan providing for outreach services that includes identifying persons in need of project services. |
709.94(f)(2) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(2) Alerting persons and their families to the availability of project services.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop a written plan providing for outreach services that includes alerting persons and their families to the availability of project services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect a written plan providing for outreach services that includes alerting persons and their families to the availability of project services. |
709.94(f)(3) LICENSURE Project management services
709.94. Project management services.
(f) The project shall develop a written plan providing for outreach services which shall include, but not be limited to:
(3) Encouraging persons to utilize the service delivery system.
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Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop a written plan providing for outreach services that includes encouraging persons to utilize the service delivery system.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedure manual has been revised to reflect a written plan providing for outreach services that includes encouraging persons to utilize the service delivery system. |