INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 14, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Passages to Recovery, 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:
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to ensure that the clinical supervisor participated in documented monthly meetings with their supervisor to discuss their duties and performance for the first 6 months of employment in that position.
Staff #2 was promoted to clinical supervisor on August 28, 2023. Clinical supervisions were reviewed for September 2023-February 2024. Monthly meetings with supervisor were not documented for September-November 2023 and January-February, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisors will receive weekly supervisions for the first 60 days of employment and monthy/as needed for the next 120 days. This will be documented in a formal supervision note and saved in the training log for the employee by the Director of Clinical Services and Chief Program Officer.
Monthly supervisions resumed with Staff #2 March 2024 to present and are documented in formal supervision notes |
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 monthly fire drill records, the facility failed to conduct an unannounced fire drill at least once a month.
Fire drill records were reviewed for June 2023-May 2024. There was no monthly fire drill conducted in the month of August 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Compliance department will run monthly fire drills in conjunction with CLASS building administrators to ensure review of safe evacuation routes of client and staff.
Compliance supervisor will review monthly fire drill logs to ensure compliance. |
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 monthly fire drill records, the facility failed to maintain a written fire drill record that included 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.
Fire drill records were reviewed for June 2023-May 2024. Drills for the months of January 2024-May 2024 did not include exit route used, problems encountered and whether the fire alarm or smoke detector was operative.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Fire drill log was updated to show exit route used, problems encountered, and whether the fire alarm or smoke detector was operative and will be completed by Compliance Officers monthly. |
709.84(b) LICENSURE Project management services
709.84. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public.
This finding was reviewed with the facility staff during the licensing process
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Plan of Correction
Hours of operation were posted on all 3 external doors of the facility to ensure viewing by general public. |
709.84(c) LICENSURE Project management services
709.84. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the telephone number to the general public for emergency purposes.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
An emergency contact number which is staffed 24/7 has been posted on all 3 external doors to the facility to ensure viewing by the general public. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of client records, the facility failed to provide documentation of disclosure to the client of criteria for admission, treatment, completion, and discharge in six of seven records.
Client #1 was admitted to the outpatient level of care on August 22, 2023, and discharged on November 14, 2023.
Client #2 was admitted to the outpatient level of care on October 3, 2023, and discharged on January 11, 2024.
Client #3 was admitted to the outpatient level of care on December 29, 2023, and discharged on March 21, 2024.
Client #4 was admitted to the outpatient level of care on August 31, 2023, and discharged on April 17, 2024.
Client #5 was admitted to the outpatient level of care on January 9, 2024, and was still an active client at the time of inspection.
Client #6 was admitted to the outpatient level of care on March 20, 2024, and was still an active client at the time of inspection.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 5, 2023, licensing inspection.
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Plan of Correction
The client handbook was updated to show admission, treatment, completion, and discharge criteria. All clients are provided a handbook at intake and it is reviewed and signed off in orientation by their assigned therapist. Documentation is placed in client chart by the assigned therapist.
Admission, discharge, treatment and completion criteria was reviewed with Client #5 and Client #6 and documented in chart by assigned therapist.
This will be reviewed monthly by Director of Clinical Services. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to provide documentation of client orientation to the project which shall include a familiarization with the project policies in six of seven records.
Client #1 was admitted to the outpatient level of care on August 22, 2023, and discharged on November 14, 2023.
Client #2 was admitted to the outpatient level of care on October 3, 2023, and discharged on January 11, 2024.
Client #3 was admitted to the outpatient level of care on December 29, 2023, and discharged on March 21, 2024.
Client #4 was admitted to the outpatient level of care on August 31, 2023, and discharged on April 17, 2024.
Client #5 was admitted to the outpatient level of care on January 9, 2024, and was still an active client at the time of inspection.
Client #6 was admitted to the outpatient level of care on March 20, 2024, and was still an active client at the time of inspection.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 5, 2023, licensing inspection.
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Plan of Correction
Client orientation documentation was updated to ensure review of policies, services, emergency evacuation plans, fee schedule, hours of operation, and other program information. Client orientation will be completed by assigned therapist.
Project policies were reviewed with Client #5 and Client #6 and documented in chart as of 07/15/2024.
Director of Clinical Services will review orientation completion monthly. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed to provide documentation of client orientation to the project which shall include a familiarization with the hours of operation in seven of seven records.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the July 5, 2023, licensing inspection.
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Plan of Correction
The client handbook was updated to show hours of operation. All clients are provided a handbook at intake and it is reviewed and signed off in orientation. Documentation is placed in client chart. Client orientation documentation was updated to ensure review of policies, services, emergency evacuation plans, fee schedule, hours of operation, and other program information. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to provide documentation of client orientation to the project which shall include a familiarization with the fee schedule in six of seven records.
Client #1 was admitted to the outpatient level of care on August 22, 2023, and discharged on November 14, 2023.
Client #2 was admitted to the outpatient level of care on October 3, 2023, and discharged on January 11, 2024.
Client #3 was admitted to the outpatient level of care on December 29, 2023, and discharged on March 21, 2024.
Client #4 was admitted to the outpatient level of care on August 31, 2023, and discharged on April 17, 2024.
Client #5 was admitted to the outpatient level of care on January 9, 2024, and was still an active client at the time of inspection.
Client #6 was admitted to the outpatient level of care on March 20, 2024, and was still an active client at the time of inspection.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 5, 2023, licensing inspection.
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Plan of Correction
The client handbook was updated to show the fee schedule. All clients are provided a handbook at intake and it is reviewed and signed off in orientation. Documentation is placed in client chart. Client orientation documentation was updated to ensure review of policies, services, emergency evacuation plans, fee schedule, hours of operation, and other program information.
Fee schedule was reviewed with Client #5 and Client #6 and documentation was placed in client chart. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on a review of client records, the facility failed to provide documentation of client orientation to the project which shall include a familiarization with the services provided in six of seven client records.
Client #1 was admitted to the outpatient level of care on August 22, 2023, and discharged on November 14, 2023.
Client #2 was admitted to the outpatient level of care on October 3, 2023, and discharged on January 11, 2024.
Client #3 was admitted to the outpatient level of care on December 29, 2023, and discharged on March 21, 2024.
Client #4 was admitted to the outpatient level of care on August 31, 2023, and discharged on April 17, 2024.
Client #5 was admitted to the outpatient level of care on January 9, 2024, and was still an active client at the time of inspection.
Client #6 was admitted to the outpatient level of care on March 20, 2024, and was still an active client at the time of inspection.
These findings were reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 5, 2023, licensing inspection.
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Plan of Correction
The client handbook was updated to show services provided. All clients are provided a handbook at intake and it is reviewed and signed off in orientation. Documentation is placed in client chart. Client orientation documentation was updated to ensure review of policies, services, emergency evacuation plans, fee schedule, hours of operation, and other program information.
Client orientation was completed with Client #5 and Client #6 and documentation was placed in the chart. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the hours of project operation to the general public.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Hours of operation were posted on all 3 external doors of the facility to ensure viewing by general public.
Compliance of these expectations will be ensured by Director of Clinical Services. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on a physical plant inspection, the facility failed to conspicuously display the telephone number to the general public for emergency purposes.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
An emergency contact number which is staffed 24/7 has been posted on all 3 external doors to the facility to ensure viewing by the general public.
Compliance of these expectations will be ensured by Director of Clinical Services. |