INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 5-8th, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, ARS of Pennsylvania 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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704.11(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
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Observations
Based on a discussion with the executive director, the facility failed to complete an overall plan for addressing training needs. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will assess facility training needs annually. Based on identified needs, Executive Director will adjust Relias training schedule to match facility needs. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a discussion with the executive director, the facility failed to complete an annual evaluation of the overall training plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director will complete, and document, annual evaluation of staff training plans in order to identify training strengths and areas of improvement. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility fire drill from November 2018 until October 2019, the facility failed to conduct fire drills at different times of the day as all twelve fire drills were conducts between the hours of 11:30-2pm with no clients on cite. These finding were discussed with facility staff during inspection process.
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Plan of Correction
The Executive Director along with the safety officer will ensure that fire drills are conducted on a monthly basis at various times of day. These drills will include documentation of participants of each drill, to include patient's.
Since audit, fire drills conducted September 2019-December 2019 included both staff and patients. |
715.9(a)(1) LICENSURE Intake
(a) Prior to administration of an agent, a narcotic treatment program shall screen each individual to determine eligibility for admission. The narcotic treatment program shall:
(1) Verify that the individual has reached 18 years of age.
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Observations
Based on a review of client records, the facility failed to provide patient # ' s 2, 4, 5, 11, 12, and 13 with 2.5 hours of psychotherapy per month during the patient ' s first 2 years of treatment. Patient # 2 was admitted on June 26, 2019 and was still active at the time of inspection. In August 2019 , the client had 1 hour of individual therapy and 0 hours of group therapy. In October 2019 , the client had 1 hour of individual therapy and 0 hours of group therapy.Patient # 4 was admitted on August 26, 2019 and was still active at the time of inspection. In September 2019 , the client had 1.5 hours of individual therapy and 0 hours of group therapy. In October 2019 , the client had 1 hour of individual therapy and 0 hours of group therapy.Patient # 5 was admitted on June 17, 2019 and was still active at the time of inspection. In September 2019 , the client had 2 hour of individual therapy and 0 hours of group therapy. In October 2019 , the client had 1 hour of individual therapy and 0 hours of group therapy.Patient # 11 was admitted on January 2, 2019 and was still active at the time of inspection. In August 2019 , the client had 30 minutes of individual therapy and 0 hours of group therapy. In September 2019 , the client had 1 hour of individual therapy and 0 hours of group therapy. In October 2019 the client had 0 hours of individual therapy and 1.5 hours of group therapy. Patient # 12 was admitted on April 20th, 2018 and was still active at the time of inspection. In August 2019 , the client had 0 hour of individual therapy and 0 hours of group therapy. In September 2019 , the client had 0 hour of individual therapy and 0 hours of group therapy.Patient # 13 was admitted on Septebmer 20, 2018 and was still active at the time of inspection. In September 2019 , the client had 1 hour of individual therapy and 0 hours of group therapy. In October 2019 , the client had 1 hour of individual therapy and 0 hours of group therapy.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will train clinical staff regarding the required 2.5 hours of counseling per month. Primary Counselors will prepare monthly reports identifying which patients did not attend group sessions and/or individual sessions the third Friday of every month. The Primary Counselor will send reports to the Clinical Supervisor and a plan of re-engagement will be established during scheduled clinical supervisions. |