INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Fellowship House, 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure a written individual training plan for each employee, appropriate to that employee's skill level was documented annually in one of two records reviewed.
Employee #1 was hired on February 1, 2022 as the project director and facility director and is still current in those positions. There was no documentation of an annual written individual training plan in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- All personnel records were reviewed by the executive team
- Training plans were developed for Project Director and Facility Director positions (attached)
- Employee #1 underwent the documented training regimen
FH Training Plan Additions
704.11(b) Staff Development Program
Facility Director
Objective: The objective of this training plan is to equip the Facility Director of Fellowship House, a substance abuse treatment center, with the necessary knowledge and skills to effectively manage and oversee the operations of the facility.
Training Topics:
1. Introduction to Fellowship House
- Overview of Fellowship House's mission, vision, and values
- Understanding the organization's structure and key stakeholders
- Familiarization with the facility's programs and services
2. Regulatory Compliance and Accreditation
- Understanding state and federal regulations applicable to substance abuse treatment centers
- Familiarization with accreditation standards and requirements (e.g., CARF, Joint Commission)
- Ensuring compliance with privacy and confidentiality laws (e.g., HIPAA)
3. Leadership and Management Skills
- Effective communication and interpersonal skills
- Conflict resolution and problem-solving techniques
- Time management and organizational skills
- Team building and staff motivation strategies
4. Facility Operations and Safety
- Understanding facility maintenance and safety protocols
- Emergency preparedness and response procedures
- Ensuring a safe and secure environment for staff and clients
- Managing facility resources and budgeting
5. Human Resources Management
- Recruitment, selection, and onboarding of staff
- Performance management and evaluation processes
- Employee training and development programs
- Ensuring a positive and inclusive work culture
6. Quality Assurance and Continuous Improvement
- Monitoring and evaluating program effectiveness
- Data collection and analysis for performance improvement
- Implementing quality assurance measures and best practices
- Incorporating client feedback and satisfaction surveys
7. Ethical and Professional Standards
- Understanding and adhering to professional codes of conduct
- Ethical decision-making and maintaining professional boundaries
- Confidentiality and privacy considerations
- Cultural competence and diversity awareness
Training Methods:
1. Classroom Training: Conduct instructor-led sessions for theoretical knowledge and interactive discussions on various topics.
2. On-the-Job Training: Provide hands-on experience and guidance while shadowing experienced staff members in different departments.
3. Workshops and Seminars: Attend relevant workshops and seminars conducted by industry experts and professional organizations.
4. Online Training: Utilize online learning platforms to access self-paced courses and resources on specific topics.
5. Case Studies and Role-Playing: Engage in practical exercises and simulations to apply knowledge and skills in real-life scenarios.
6. Guest Speakers: Invite subject matter experts and professionals from related fields to share their insights and experiences.
Training Evaluation:
1. Pre and Post-Assessments: Conduct assessments before and after training to measure knowledge gain and identify areas for improvement.
2. Feedback Surveys: Collect feedback from the Facility Director regarding the effectiveness and relevance of the training sessions.
3. Performance Evaluation: Monitor the Facility Director's performance and progress in implementing the acquired knowledge and skills.
4. Ongoing Support: Provide ongoing support and mentorship to address any challenges or questions that may arise after the training.
By implementing this comprehensive training plan, the Facility Director of Fellowship House will be equipped with the necessary skills and knowledge to effectively manage the substance abuse treatment center, ensuring the provision of high-quality services to clients and the overall success of the organization.
Project Director
Objective: The objective of this training plan is to provide the Project Director of Fellowship House, a substance abuse treatment facility, with the necessary skills and knowledge to successfully plan, execute, and oversee projects related to the facility's operations and improvement.
Training Topics:
1. Project Management Fundamentals
- Introduction to project management principles, methodologies, and best practices
- Understanding the project lifecycle and key project management processes
- Defining project goals, objectives, and deliverables
- Developing project plans, timelines, and budgets
2. Stakeholder Management
- Identifying and engaging key stakeholders in project planning and execution
- Effective communication strategies with stakeholders, including staff, clients, and external partners
- Managing stakeholder expectations and addressing concerns or conflicts
3. Project Scope and Requirements
- Defining project scope and identifying project requirements
- Conducting needs assessments and gap analyses
- Prioritizing project activities and deliverables
- Managing project changes and scope creep
4. Resource Management
- Identifying and allocating project resources, including personnel, equipment, and budget
- Developing resource management plans and schedules
- Monitoring resource utilization and making adjustments as needed
- Managing vendor relationships and contracts
5. Risk Management
- Identifying and assessing project risks and potential obstacles
- Developing risk mitigation strategies and contingency plans
- Monitoring and controlling project risks throughout the project lifecycle
- Implementing quality assurance measures to minimize risks
6. Project Monitoring and Evaluation
- Establishing project monitoring and evaluation mechanisms
- Tracking project progress, milestones, and deliverables
- Conducting regular project status meetings and reporting
- Evaluating project outcomes and lessons learned
7. Leadership and Team Management
- Effective leadership skills for project management
- Building and managing project teams
- Motivating and empowering team members
- Resolving conflicts and fostering collaboration
8. Continuous Improvement and Lessons Learned
- Incorporating continuous improvement practices into project management
- Conducting post-project evaluations and capturing lessons learned
- Implementing feedback mechanisms for ongoing improvement
- Applying project management tools and software effectively
Training Methods:
1. Classroom Training: Conduct instructor-led sessions for theoretical knowledge and interactive discussions on project management concepts and techniques.
2. Case Studies and Simulations: Engage in practical exercises and simulations to apply project management principles in real-life scenarios.
3. On-the-Job Training: Provide hands-on experience and guidance while working on actual projects under the supervision of experienced project managers.
4. Workshops and Webinars: Attend relevant workshops and webinars conducted by industry experts and professional organizations.
5. Self-Study and Online Resources: Utilize self-paced online courses, books, and resources to deepen understanding of project management concepts.
6. Mentoring and Coaching: Assign a mentor or coach who can provide guidance and support throughout the training process.
Training Evaluation:
1. Pre and Post-Assessments: Conduct assessments before and after training to measure knowledge gain and identify areas for improvement.
2. Project Performance Evaluation: Monitor the Project Director's performance in planning and executing projects, assessing adherence to project management principles.
3. Feedback Surveys: Collect feedback from the Project Director regarding the effectiveness and relevance of the training sessions.
4. Ongoing Support: Provide ongoing support and mentorship to address any challenges or questions that may arise during project management.
By implementing this comprehensive training plan, the Project Director of Fellowship House will be equipped with the necessary skills and knowledge to effectively plan, execute, and oversee projects, contributing to the success and continuous improvement of the substance abuse treatment facility.
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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 personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment, in one applicable record reviewed.
Employee #1 was hired on February 1, 2022 as the project director and facility director and is still current in those positions. There was no documentation of employee #1 being instructed in the use of the fire extinguisher upon employment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Employee #1 was instructed in the proper use of fire extinguishers on the property per PA Department of Labor materials (can provide if needed)
- Training was documented in our Emergency Safety Log
- Employee #1 will ensure all corrective actions (training and logging in Emergency Log) will be implemented; all staff will be trained on fire extinguisher safety twice yearly
- New staff will be trained upon employment by Facility Director (Employee #1) |
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 documents submitted and discussion with facility staff, the facility failed to conduct unannounced fire drills at least once a month since the facility was first licensed in September 2022.
No unannounced fire drills had been conducted from September 2022 to May 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Unannounced fire drills have been conducted on the following dates by the Facility Director (Employee #1):
o June 11th, 2023
o June 29th, 2023
o July 5th, 2023
o July 26th, 2023
o August 1st, 2023
o August 9th, 2023
- Facility Director (Employee #1) will ensure there are two (2) fire drills per month for the rest of 2023 in order to make up for the 9 missed drills in the past.
- Facility Director (Employee #1) will oversee and conduct one (1) fire drill per month starting in 2024 and moving forward after that
- Counselor's Assistant (Employee #2) will monitor all fire drill activities and ensure they are completed by observing and recording the drills. Counselor's Assistant will also document the details of all fire drills and implement any needed improvements to process. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies, in one applicable record reviewed.
Employee #1 was hired on February 1, 2022 as the project director and facility director and is still current in those positions. There was no documentation of employee #1 being trained to perform assigned tasks during emergencies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Facility Director (Employee #1) has been trained on all emergency procedures and tasks
- Facility Director (Employee #1) has trained all staff to perform assigned tasks during emergencies
- Facility Director (Employee #1) has entered documentation of this training into our Emergency Safety Log
- Facility Director (Employee #1) has reviewed all policies & procedures pertaining to personnel being trained to perform assigned tasks during emergencies. Moving forward, he will be responsible for implementing the corrective actions of timely training and documentation of training. He will make sure new hires are trained in emergencies per emergency policies & procedures.
- The governing body will review new employee files within two weeks of hire. All employee files will be reviewed yearly by the governing body.
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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 administrative documents submitted and discussion with facility staff, 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
Plan of Correction
- All subsequent fire drills have been documented by Facility Director (Employee #1) in drill records including the date, time, amount of time it took for evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
- Facility Director (Employee #1) has reviewed all fire drill policies & procedures.
- Facility Director (Employee #1) will implement corrective action by ensuring that all future fire drills are documented in our Emergency Log. |
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 administrative documents submitted and review of the facility ' s policy and procedure manual, the facility failed to document written procedures for the management of treatment/rehabilitation services for clients.
The facility ' s written procedures in the policy manual document responsibilities of the project director for ensuring services occur, are reviewed and monitored. The procedures do not identify treatment/rehabilitation services from intake to discharge for clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Treatment/rehabilitation services from intake to discharge have been entered into the Policies & Procedures by Facility Director (Employee #1).
- Facility Director (Employee #1) will implement corrective action by reviewing policies & procedures and updating when applicable. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of administrative documents submitted and review of the facility ' s policy and procedure manual, the facility failed to develop written policies and procedures on client rights that includes the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Facility Director (Employee #1) has entered a clause under 'Client Rights' detailing a client's right to inspect their own records has been added to our Polices & Procedures (see below).
- Facility Director (Employee #1) will review policies & procedures regularly and update when applicable.
- Facility Director (Employee #1) will monitor all Client activity and ensure this policy is put into action.
"Clients have the right to inspect their own records. The project, facility or Clinical Director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record."
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709.30 (4) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of administrative documents submitted and review of the facility ' s policy and procedure manual, the facility failed to develop written policies and procedures on client rights that includes clients have the right to appeal a decision limiting access to their records to the director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Facility Director (Employee #1) entered a clause under 'Client Rights' detailing a client's right to appeal a decision limiting access to their own records has been added to our Polices & Procedure.
- Facility Director (Employee #1) will review policies & procedures regularly and update when applicable.
- Facility Director (Employee #1) will ensure that this client policy is put into action.
Clients have the right to appeal a decision limiting access to their records to the director.
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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 administrative documents submitted and review of the facility ' s policy and procedure manual, the facility failed to develop written policies and procedures to respond to selling or use of illicit drugs on the premises.
The facility policy only identifies selling or using illicit drugs on the premises is prohibited, there are no documented procedures for responding if illicit drugs are sold or used on the premises.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Facility Director (Employee #1) entered a series of sub-chapters under 'Unusual Incidents' detailing the response for sale or use of illicit drugs on the premises have been added to our Polices & Procedures (below)
- Facility Director (Employee #1) will review policies and procedures regularly and update when applicable
- Facility Director (Employee #1) will ensure new Unusual Incident policies are put into action.
709.34 (a) (2) Reporting the Sale or Use of Illicit Drugs
2.1. Any staff member who becomes aware of the sale or use of illicit drugs within the substance abuse treatment center premises must immediately report the incident to their immediate supervisor (facility director).
2.2. The supervisor shall document the incident and report it to the designated authority within the organization.
2.3. The designated authority will ensure that appropriate actions are taken, which may include involving law enforcement agencies if necessary. Anyone caught using or selling illicit drugs will be immediately asked to leave the property permanently.
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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 administrative documents submitted and review of the facility ' s policy and procedure manual, the facility failed to develop written policies and procedures to respond 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
Plan of Correction
- Facility Director (Employee #1) entered sub-chapters under 'Unusual Incidents' detailing the response for an event at the facility requiring the presence of police, fire or ambulance personnel have been added to our Polices & Procedures (below)
- Facility Director (Employee #1) will review policies and procedures regularly and update when applicable
- Facility Director (Employee #1) will ensure new Unusual Incident policies are put into action.
709.34 (a) (6) Event Requiring the Presence of Police, Fire, or Ambulance Personnel
6.1. In the event of an emergency situation that requires the presence of police, fire, or ambulance personnel, staff members must immediately contact the appropriate emergency services.
6.2. Staff members should provide accurate and detailed information about the incident, including the location, nature of the emergency, and any potential risks or hazards.
6.3. Following the incident, staff members must report the event to their immediate supervisor, who will document the incident and ensure that any necessary follow-up actions are taken.
6.4 Staff members should do their best o maintain the confidentiality of all clients. They must not disclose any personal information to any emergency service memebrs without consent of client.
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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 administrative documents submitted and review of the facility ' s policy and procedure manual, the facility failed to develop written policies and procedures to respond to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
The facility ' s policy just states it will contact the CDC.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Facility Director (Employee #1) entered sub-chapters under 'Unusual Incidents' detailing the response to an outbreak of contagious disease requiring the CDC has been added to our Polices & Procedures (below)
- Facility Director (Employee #1) will review policies and procedures regularly and update when applicable
- Facility Director (Employee #1) will ensure new Unusual Incident policies are put into action.
709.34 (a) (8) Outbreak of a Contagious Disease Requiring the Centers for Disease Control (CDC)
8.1. If an outbreak of a contagious disease occurs within the substance abuse treatment center, staff members must immediately notify the designated authority.
8.2. The designated authority will contact the appropriate health authorities, including the Centers for Disease Control (CDC), to report the outbreak and seek guidance on containment and prevention measures.
8.3. Staff members should follow all recommended protocols and guidelines provided by the health authorities to minimize the spread of the contagious disease. This may include evacuation or quarantine.
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709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on a review of administrative documents submitted and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures that included the documentation of the unusual incident for the following unusual incidents:
-Related to 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.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
-Theft, burglary, break-in or similar incident at the facility.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
-Fire or structural damage to the facility.
- Outbreak of A Contagious Disease Requiring Centers for Disease Control Notification
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Facility Director entered a section under 'Unusual Incidents' detailing the documentation of all unusual incidents has been added to our Polices & Procedures (below)
- Facility Director (Employee #1) will review policies and procedures regularly and update when applicable
- Facility Director (Employee #1) will ensure new Unusual Incident policies are put into action.
709.34 (b) (1) Documenting Unusual Incidents
1.1. All unusual incidents, including those mentioned in the list below, must be documented in a timely and accurate manner.
- Related to 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.
- Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
- Theft, burglary, break-in or similar incident at the facility.
- Event at the facility requiring the presence of police, fire or ambulance personnel.
- Fire or structural damage to the facility.
- Outbreak of A Contagious Disease Requiring Centers for Disease Control Notification
1.2. Staff members involved in or witnessing an unusual incident must complete an incident report form, providing detailed information about the incident, including date, time, location, individuals involved, and a description of the incident.
1.3. Incident reports should be submitted to the designated authority within a specified timeframe, as outlined in the organization's policies and procedures.
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709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of administrative documents submitted and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures that included the prompt review and identification of the causes directly or indirectly responsible for the unusual incident for the following unusual incidents:
-Related to 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.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
-Theft, burglary, break-in or similar incident at the facility.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
-Fire or structural damage to the facility.
- Outbreak of A Contagious Disease Requiring Centers for Disease Control Notification
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Facility Director (Employee #1) entered a section under 'Unusual Incidents' detailing the prompt review and identification of the causes directly or indirectly responsible for unusual incidents has been added to our Polices & Procedures (attached)
- Facility Director (Employee #1) will review policies and procedures regularly and update when applicable
- Facility Director (Employee #1) will ensure new Unusual Incident policies are put into action.
709.34 (b) (2) Review and Identification of Causes of Unusual Incidents
2.1. The designated authority shall review all incident reports to identify the causes and contributing factors of unusual incidents listed here:
- Related to 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.
- Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
- Theft, burglary, break-in or similar incident at the facility.
- Event at the facility requiring the presence of police, fire or ambulance personnel.
- Fire or structural damage to the facility.
- Outbreak of A Contagious Disease Requiring Centers for Disease Control Notification
2.2. The review process may involve conducting interviews, gathering additional information, and analyzing relevant data to determine the root causes of the incidents.
2.3. The findings of the review shall be documented and used to develop appropriate corrective actions to prevent similar incidents from occurring in the future.
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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 administrative documents submitted and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures that included the implementation of a timely and appropriate corrective action plan, when indicated for the following unusual incidents:
-Related to 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.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
-Theft, burglary, break-in or similar incident at the facility.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
-Fire or structural damage to the facility.
- Outbreak of A Contagious Disease Requiring Centers for Disease Control Notification
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Facility Director (Employee #1) section under 'Unusual Incidents' detailing the implementation of a timely and appropriate corrective action plan for designated unusual incidents has been added to our Polices & Procedures (attached)
- Facility Director (Employee #1) will review policies and procedures regularly and update when applicable
- Facility Director (Employee #1) will ensure new Unusual Incident policies are put into action.
709.34 (b) (3) Implementation of a Corrective Action Plan for Unusual Incidents
3.1. Based on the findings of the incident review, a corrective action plan shall be developed and implemented to address the identified causes and prevent recurrence.
3.2. The corrective action plan may include changes to policies, procedures, training programs, or other measures deemed necessary to mitigate the risks associated with unusual incidents.
3.3. The designated authority shall ensure that the corrective action plan is communicated to all relevant staff members and that its implementation is monitored and evaluated for effectiveness.
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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 administrative documents submitted and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures that included the ongoing monitoring of the corrective action plan for the following unusual incidents:
-Related to 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.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
-Theft, burglary, break-in or similar incident at the facility.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
-Fire or structural damage to the facility.
- Outbreak of A Contagious Disease Requiring Centers for Disease Control Notification
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Facility Director (Employee #1) section under 'Unusual Incidents' detailing the ongoing monitoring of the corrective action plan for designated unusual incidents has been added to our Polices & Procedures (below)
- Facility Director (Employee #1) will review policies and procedures regularly and update when applicable
- Facility Director (Employee #1) will ensure new Unusual Incident policies are put into action.
709.34 (b) (4) Ongoing Monitoring for New Action Plans for Unusual Incidents
4.1. The designated authority shall establish a system for ongoing monitoring and evaluation of the effectiveness of implemented corrective action plans.
4.2. Regular reviews and assessments shall be conducted to identify any new or emerging risks or incidents that require the development of additional action plans.
4.3. Staff members shall be encouraged to report any potential risks or incidents promptly to ensure timely intervention and the development of appropriate action plans.
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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 administrative documents submitted and the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures 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 for the following unusual incidents:
-Related to 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.
-Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
-Theft, burglary, break-in or similar incident at the facility.
-Event at the facility requiring the presence of police, fire or ambulance personnel.
-Fire or structural damage to the facility.
- Outbreak of A Contagious Disease Requiring Centers for Disease Control Notification
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Plan of Correction
- Facility Director (Employee #1) section under 'Unusual Incidents' detailing the reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws for designated unusual incidents has been added to our Polices & Procedures (below)
- Facility Director (Employee #1) will review policies and procedures regularly and update when applicable
- Facility Director (Employee #1) will ensure new Unusual Incident policies are put into action.
709.34 (b) (5) Ensuring Compliance with State and Federal Confidentiality Laws
5.1. The substance abuse treatment center shall establish a reporting mechanism that ensures compliance with State and Federal confidentiality laws.
5.2. Staff members must be trained on the proper reporting procedures to protect the confidentiality of individuals involved in unusual incidents.
5.3. The reporting mechanism should include clear guidelines on what information can be shared, with whom, and under what circumstances, while maintaining strict adherence to confidentiality laws.
5.4. This reporting mechanism will be the duty of the Facility Director. Upon review of the updated Polices & Procedures, the FD will consult with State and Federal Regulations to ensure that procedures and protocols are aligned. If/when an incident does occur, it will be the FD's job to ensure that these protocols are followed to State and Federal standards. If/when they are not, the FD will email the PA Department of Health and the Federal Health Department to update them on issues with Unusual Incidents.
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