INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 29. 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Keystone Drug and Alcohol 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection conducted on August 29, 2024, the facility failed to ensure fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. This was the facility's first onsite licensing inspection and there was no documentation that the fire extinguishers had ever been inspected. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has appointed a safety officer to manage and perform monthly inspections on fire safety, and physical plant standards to ensure we are in compliance with regulations. The safety officer has reached out to local fire extinguisher inspectors (Cintas) to schedule our annual inspection, and tag and document fire extinguisher inspections. The facility will maintain a fire extinguisher inspection log detailing the dates and results of inspections. The program director will monitor adherence to this plan on a quarterly basis during facility walk through. The facility will be in full compliance with this standard on September 23, 2024. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment, in three out of three personnel records reviewed. Employee #1 was hired as the Project Director/Facility Director on January 15, 2024 and is still current in that position. There was no documentation they were instructed in the use of the fire extinguisher training upon staff employment. Employee #2 was hired on as counselor on December 04, 2023 and is still current in that position. There was no documentation they were instructed in the use of the fire extinguisher training upon staff employment. Employee #3 was hired on a counselor on April 12, 2024 and is still current in that position. There was no documentation they were instructed in the use of the fire extinguisher training upon employment. These findings were discussed with the facility during the licensing process.
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Plan of Correction
The program director will revise staff orientation procedure to include fire extinguisher training. Each staff member will complete the Bayside Fire Safety training upon hire and the certificate of completion will be kept in the HR file. For all existing staff, the Fire Extinguisher Training will be completed and on file by September 12, 2024. At which time the facility will be in full compliance with this regulation. This will be monitored by the safety officer quarterly. |
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 review of facility's fire drill logs from October 2023-August 2024, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of unannounced fire drills occurring for the months of October and November 2023. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The safety officer will conduct training sessions on the importance of fire drills. A Fire drill log will continue to be maintained to document each drill, including date, time, staff participation, fire exits, and any issues identified. The safety officer will review drill performance during monthly staff meetings to assess compliance and effectiveness. The program director will monitor adherence to fire drill schedule on a quarterly basis. The facility is in compliance with this standard as of September 5, 2024. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to properly ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies in three out of three records reviewed.Employee #1 was hired as the Project Director/Facility Director on January 15, 2024 and is still current in that position. There was no documentation they were trained to perform assigned tasks during emergencies. Employee #2 was hired on as counselor on December 04, 2023 and is still current in that position. There was no documentation they were trained to perform assigned tasks during emergencies. Employee #3 was hired on a counselor on April 12, 2024 and is still current in that position. There was no documentation they were trained to perform assigned tasks during emergencies. These findings were discussed during the licensing process.
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Plan of Correction
The program director will revise staff orientation procedures to include training to perform assigned tasks during emergencies. This will include an orientation with the safety officer. This training will be documented and retained in the employee's HR file. Each of the current employees will review the emergency procedures with the safety officer. Adherence to this policy will be reviewed monthly by the safety officer, and quarterly by the program director. The facility will be in compliance with this regulation by September 12, 2024. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from October 2023 through August 2024, the facility failed to properly prepare alternate exit routes as the same exit route was documented in each fire drill. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The safety officer will conduct training sessions on the importance of fire drills. A Fire drill log will continue to be maintained to document each drill, including date, time, staff participation, fire exits, and any issues identified. The safety officer will ensure the use of alternative exit routes during fire drills. The program director will monitor adherence to this standard on a quarterly basis. The facility is in compliance with this standard as of September 5, 2024. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in five out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.Client #3 was admitted on January 9, 2024 and was still active at the time of the inspection.Client #4 was admitted on May 3, 2024 and was still active at the time of the inspection.Client #5 was admitted on March 21, 2024 and was discharged on June 27, 2024.Client #6 was admitted on February 27, 2024 and was discharged on May 20, 2024.Client #7 was admitted on March 22, 2024 and was discharged on June 7, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
For current clients, the administrative assistant will develop a release of information form for the funding source to be signed by all current clients (including client #3 and #4).
For all future clients, the administrative assistant will develop a standard release of information form for the funding source. This release of information form will be explained to each client and signed as a part of the intake process. The billing department will confirm that a proper release of information is signed by each client prior to billing for services.
The program director will monitor adherence to this as a part of regular monthly chart monitoring activities. The facility will be in full compliance with this regulation by Thursday, September 12, 2024.
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709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the purpose of the disclosure in one out of seven records reviewed.Client #4 was admitted on May 3, 2024 and was still active at the time of the inspection. A consent form dated June 11, 2024 to a family member did not list the purpose of the disclosure.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
It is company policy for all facility staff to be trained in confidentiality as a part of the orientation process. The program director will review the proper way to complete a consent form to include checking the appropriate boxes for "purpose of disclosure". For client #4, a new consent will be developed, and the "purpose of disclosure" option will be selected in the form. The program director will monitor all other active charts to ensure compliance with this standard. The program director will continue to monitor compliance with this standard as a part of regular monthly chart audits. This standard will be in full compliance by Thursday September 12, 2024. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to document a complete psychosocial evaluation in five out of seven applicable records. Client #1 was admitted on January 9, 2024 and was still active at the time of the inspection. Client #3 was admitted on April 8, 2024 and was still active at the time of the inspection. Client #4 was admitted on May 3, 2024 and was still active at the time of the inspection.Client #5 was admitted on March 21, 2024 and was discharged on June 27, 2024.Client #6 was admitted on February 27, 2024 and was discharged on May 20, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A psychosocial evaluation is an assessment used to identify client barriers to recovery, strengths, and needs. This assessment also helps to develop the comprehensive treatment plan. The program director will utilize regular supervision to train counselors on the correct way to utilize the data collected in the data collection portion of the psychosocial assessment in order to assess the client, in order identify client strengths, barriers, and needs. Reviewing the psychosocial assessment will be a regular topic in supervision over the next 6 months. As a part of the training process and addendum will be added to the psychosocial assessments of clients #'s 1, 3, 4, 5, and 6. The program director will continue to monitor compliance with this regulation during supervision, and in regular monthly chart audits. The facility will be in full compliance with this standard by Thursday, September 19, 2024. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within the regulatory timeframe in three out of seven records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed by at time of intake.Client #1 was admitted on January 9, 2024 and was still active at the time of the inspection. There was no documentation of a preliminary treatment plan at the time of the inspection.Client #6 was admitted on February 27, 2024 and was discharged on May 20, 2024. The plan was completed on April 10, 2024.Client #7 was admitted on March 22, 2024 and was discharged on June 7, 2024. The plan was completed on April 11, 2024These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During regular monthly chart audits in April 2024, the program director identified that the facility was not using a preliminary treatment and rehabilitation plan. At that time, we developed a preliminary treatment plan and began to implement this immediately. This included putting a preliminary treatment plan in charts the were not in compliance (clients #'s 1, 6, and7). The facility has since been using a preliminary treatment plan as a part of the intake process. The program director will continue to monitor compliance with this standard as a part of regular monthly chart audits. The facility has been incompliance with this standard since April 2024, as all clients admitted past that date have a preliminary treatment plan as a part of their intake process. |
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 the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in six out of seven client records reviewed. Client #1 was admitted on January 9, 2024 and was still active at the time of the inspection. The treatment plan was dated February 9, 2024.Client #3 was admitted on April 8, 2024 and was still active at the time of the inspection.The treatment plan was dated April 12, 2024.Client #4 was admitted on May 3, 2024 and was still active at the time of the inspection. The treatment plan was dated May 9, 2024.Client #5 was admitted on March 21, 2024 and was discharged on June 27, 2024. The treatment plan was dated March 26, 2024.Client #6 was admitted on February 27, 2024 and was discharged on May 20, 2024. The treatment plan was dated February 28, 2024.Client #7 was admitted on March 22, 2024 and was discharged on June 7, 2024. The treatment plan was dated March 26, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During regular supervision, the program director will train counseling staff on the development of the master treatment plan. This training and discussion will specifically include the "type and frequency" of treatment and rehabilitation services. For example: "the client will attend individual sessions weekly" "the client will attend 3 IOP group sessions per week". The program director will review previous treatment plans with counselors as a method of training. The program director will monitor compliance with this standard during regular monthly chart audits as well as in supervision sessions. This regulation will be in full compliance by September 12, 2024. |
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 outpatient client records, the facility failed to document treatment plan updates within the regulatory timeframe in four out of six records reviewed.Client #1 was admitted on January 9, 2024 and was still active at the time of the inspection. A treatment plan update was completed on April 24, 2024 and an update was due no later than June 24, 2024; however, it was not completed until June 26, 2024.Client #2 was admitted on March 29, 2024 and was still active at the time of the inspection. A treatment plan update was completed on June 4, 2024 and an update was due no later than August 4, 2024; however, none was completed.Client #5 was admitted on March 21, 2024 and was discharged on June 27, 2024. A treatment plan was completed on March 26, 2024 and an update was due no later than May 26, 2024; however, none was completed.Client #6 was admitted on February 27, 2024 and was discharged on May 20, 2024. A treatment plan was completed on February 28, 2024 and an update was due no later than April 29, 2024; however, none was completed.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It is company policy for treatment plans to be updated at least every 60 days. The program director will review this policy with counseling staff during supervisory sessions. In the event that a client is a no call no show on the date scheduled for the treatment plan update, the therapist will complete the update in the client's absence, and document this in the chart. The program director will increase regular chart audits to monitor compliance with this standard. The facility will be in compliance with this standard by September 12, 2024. |
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 client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 90 days following admission.Client #1 was admitted on January 9, 2024 and was still active at the time of the inspection. A case consultation was completed on April 24, 2024 and the next consultation was due no later than July 24, 2024; however, none was completed.Client #2 was admitted on March 29, 2024 and was still active at the time of the inspection. A case consultation was due no later than June 29, 2024; however, it was not completed until July 17, 2024.Client #5 was admitted on March 21, 2024 and was discharged on June 27, 2024. A case consultation was due no later than June 21, 2024; however, none was completed.Client #6 was admitted on February 27, 2024 and was discharged on May 20, 2024. A case consultation was due no later than May 28, 2024; however, none was completed.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
During supervisory sessions, the program director will discuss timeliness with documentation deadlines and time management with the counseling staff. The program director will work with the counseling staff to develop a system for entering case consultations within the 90 day timeframe. Compliance with this standard will be monitored in regular chart audits. All current clients will be reviewed to ensure case consultations are conducted nd entered in the client record. The facility will be in full compliance with this standard by September 19, 2024. |