INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 13, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Engagement, 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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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on October 13, 2022, the facility failed to ensure the hot water temperature may not exceed 120F.
The facility ' s bathroom water temperature was 130F.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director had the Hot Water Heater's Temperature adjusted so the water was below 120 F. The Facility Director will verify the water temperature is reviewed quarterly, to make sure that the temperature is remains in the assigned temperature of below 120F. |
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 fire drills from November 2021 to October 2022, the facility failed to maintain a written fire drill log that included 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 Facility Director updated documentation to state the the Fire alarm was operational when the fire drill was completed. This notation will be completed and verified by the Facility Director during every fire drill, to verify the fire alarm was operational at the time of the drill. Additionally any problems that occurred will be noted in the log for each fire drill. |
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 seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients related to case consultations occurring every ninety days in three records reviewed.
Client #3 was admitted on July 12, 2022 and was current at the time of inspection. There was no documentation of a case consultation occurring.
Client # 4 was admitted on April 25, 2022 and was current at the time of the inspection. There was no documentation of a case consultation occurring.
Client #5 was admitted on April 21, 2022 and was current at the time of the inspection. There was no documentation of a case consultation occurring.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervision was completed by the Facility Director on 10/21/2022 with identification the proper manner in which to document case consultations and the time frame required for this to occur. The Facility Director will Quarterly review charts to verify the appropriate documentation for case consultations occur. |
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.
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Observations
Based on a review of administrative documentation submitted, the facility failed to 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.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has appealed for an exception for the accounting practices, since the facility does not make the 500,000. If the facility is not granted an exception the facility will 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. This will be completed ASAP, if it's required. |
709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the date, event or condition upon which the consent will expire in five records reviewed.
Client #1 was admitted on October 10, 2022 and was current at the time of the inspection. Three informed and voluntary consent forms in the client record did not provide the date, event or condition upon which the consents would expire.
Client #3 was admitted on July 12, 2022 and was current at the time of inspection. Three informed and voluntary consent forms in the client record did not provide the date, event or condition upon which the consents would expire.
Client #5 was admitted on April 21, 2022 and was current at the time of the inspection. Three informed and voluntary consent forms in the client record did not provide the date, event or condition upon which the consents would expire.
Client #6 was admitted on August 24, 2022 and discharged on August 26, 2022. Two informed and voluntary consent forms in the client record did not provide the date, event or condition upon which the consents would expire.
Client #7 was admitted on July 26, 2022 and discharged on September 16, 2022. Three informed and voluntary consent forms in the client record did not provide the date, event or condition upon which the consents would expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
After a Supervision occurred discussing the issue that the date or condition of a consent not expiring was occurred, it was noted that in the original form the client signed it has the ending date, but through finalizing in the electronic chart, it does not carry over to the final form. This issue was corrected 10/21/2022. Consents now have the condition visible for the condition in which a consent will expire and the electronic error corrected which did not allow tis to be seen. The Facility Director will conduct quarterly chart reviews to verify this issue does not repeat. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the facility failed to develop treatment and rehabilitation plans with the client that included the frequency of treatment and rehabilitation services in all seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director conducted a supervision with staff discussing the issue with documentation of frequency of rehabilitation services not occurring. The documentation and manner to complete this documentation on treatment plans for all clients moving forward, along with updating previous treatment plans of current clients to include said frequency. This will be reviewed by the Facility Director in charts quarterly to ensure the issue does not occur again. |
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
Based on a review of seven client records, the facility failed to develop treatment and rehabilitation plans with the client that included the proposed type of support service in all seven records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Supervision occurred on 10/21/2021 by the Facility Director with all team members discussing that the treatment plan for all clients should include a statement relating the proposed type of support services clients are choosing to engage in along with the Substance Use Disorder counseling they are receiving at Engagement, LLC. Treatment pans will be reviewed quarterly by the Facility Director to ensure that the required support services are included with all treatment plans, in order to ensure this issue does not occur. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of seven client records, the facility failed to ensure there was a complete client record on an individual with information relative to the client's involvement with the project that included case consultation notes in two applicable discharged records.
Client #6 was admitted on August 24, 2022 and discharged on August 26, 2022.
Client #7 was admitted on July 26, 2022 and discharged on September 16, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director conducted an additional supervision with staff discussing the issue with making sure case consultations are completed in a timely manner, minimally every 90 days for outpatient level of care and every 45 days, for partial hospitalization level of care. If the individual client has not reached 90 days in outpatient or 45 days in partial, a case consult will be completed at the time of discharge. The completion of case consultation forms will be be reviewed by the Facility Director in charts quarterly to ensure the issue does not occur again. |