INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 27, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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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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 September 2021 thru September 2022 the facility failed to ensure that the fire drill record included the exit route used and whether the fire alarm or smoke detector was operative.
There findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the annual inspection conducted on October 18, 2021.
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Plan of Correction
Fire/Emergency Drill Report was updated on 10/5/2022 to include check boxes identifying weather the fire alarm was sound and operative/no operative. A line was also added to identify which exits were used during the drill. Executive Director will ensure updated forms are utilized monthly. |
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
Based on a review of fire drills from September 2021 thru September 2022, the facility failed to document if the facility set off a fire alarm or smoke detector during each fire drill.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the annual inspection conducted on October 18, 2021.
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Plan of Correction
Fire/Emergency Drill Report was updated on 10/5/2022 to include check boxes identifying weather the fire alarm was sound and operative/no operative. Executive Director will ensure updated forms are utilized monthly. |
715.19(1) LICENSURE Psychotherapy services
A narcotic treatment program shall provide individualized psychotherapy services and shall meet the following requirements:
(1) A narcotic treatment program shall provide each patient an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which shall be individual psychotherapy. Additional psychotherapy shall be provided as dictated by ongoing assessment of the patient.
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Observations
Based on a review of eight patient records, the facility failed to provide four applicable patients an average of 2.5 hours of psychotherapy per month during the patient 's first 2 years, 1 hour of which is individual psychotherapy.
Patient # 1 was admitted on June 22, 2022 and was still active at the time of the inspection. In June 2022, the patient had 1 hour of individual therapy. In July 2022, the patient only had 1.5 hours of group therapy. In August 2022, the patient received 0 hours of individual therapy and 0 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.
Patient # 3 was admitted on February 21, 2022 and was an active client at the time of inspection. In April 2022, the patient only had 1 hour of individual therapy. In May 2022, the patient only had 1 hour of individual therapy. In June 2022, the patient only had 1 hour of individual therapy. In July 2022, the patient only had 30 minutes of individual therapy. In August 2022, the patient only had 1.5 hours of individual therapy. There was no documentation of patient no shows or cancellations during those time periods.
Patient # 4 was admitted on December 8, 2020 and was still active at the time of the inspection. In July 2022, the patient only had 1.5 hours of group therapy. In August 2022, the patient only had 1.5 hours of group therapy. There was no documentation of patient no shows or cancellations during those time periods.
Patient #5 was admitted on April 8, 2021 and was discharged on August 5, 2022. In April 2022, the patient only had 1 hour of individual therapy. In June 2022, the patient only had 1 hour of individual therapy. In July 2022, the patient only had 1 hour of individual therapy. In August 2022, the patient only had 15 minutes of individual therapy. There was no documentations of patient no shows or cancellation during those time periods.
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 review Patient Engagement report to identify any patients that did not attend group sessions and/or individual sessions the third Friday of every month. Primary Counselor and Clinical Supervisor will discuss any engagement concerns in supervision. |
715.23(b)(22) LICENSURE Patient records
(b) Each patient file shall include the following information:
(22) Aftercare plan, if applicable.
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Observations
Based on a review of eight patient records, the facility failed to provide a complete patient record, which is to include an aftercare plan in two patient records reviewed.
Patient #5 was admitted on April 8, 2021 and was discharged on August 5, 2022. There was not documentation of an aftercare plan being completed in the patient record.
Patient #8 was admitted on September 12, 20218 and was discharged on January 13, 2022. There was not documentation of an aftercare plan being completed in the patient record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Clinical Services will complete a clinical training on 11/11/22. This training will include a review of aftercare planning. Primary Counselor will ensure all patient's with planned discharge receive and aftercare plan prior to discharge. Clinical Supervisor will audit all discharge charts within 48 hours of discharge to ensure deficiency does not reoccur. |
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 eight client records, the facility failed to ensure that comprehensive treatment plans included the type and frequency of treatment and services in all eight records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director of Clinical Services will complete a treatment plan training on 11/11/22. This training will include information on including type and frequency of treatment services on all patient treatment plans. Primary Counselor will document type and frequency of treatment services within the patient's comprehensive treatment plan's goal/objective. Clinical Supervisor will audit treatment plans to ensure this deficiency does not reoccur. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of eight client records, the facility failed to document treatment plan updates within the regulatory timeframe in four records reviewed.
Client #2 was admitted on June 6, 2022 and was still active at the time of the inspection. A treatment plan update was completed on June 17, 2022, and the next update was due no later than August 17, 2022; however, there was no update documented in the record until September 8, 2022.
Client #3 was admitted on February 21, 2022 and was still active at the time of the inspection. A treatment plan update was completed on July 22, 2022, and the next update was due no later than September 22, 2022, however, there was no update documented in the record at the time of the inspection.
Client #4 was admitted on December 8, 2020 and was still active at the time of the inspection. A treatment plan update was completed on April 13, 2022, and the next update was due no later than June 13, 2022; however, there was no update documented in the record until August 12, 2022.
Client #5 was admitted on April 8, 2021 and was discharged on August 5, 2022. A treatment plan update was completed on May 27, 2022, and the next update was due no later than July 27, 2022; however, there was no update documented in the 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
Director of Clinical Services will complete a treatment plan training on 11/11/22. This training will include information regarding requirement of treatment plan updates reviewed and signed at least every 60 days. Primary Counselor will identify patient's treatment plan "next review date" on their problem list and will ensure plans are reviewed and updated by the next review date every 60 days. Clinical Supervisor will track next review dates weekly to ensure this deficiency does not reoccur. |