INITIAL COMMENTS
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This report is a result of a complaint investigation conducted on September 23, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site complaint investigation, the allegations against James A. Casey House were unable to be substantiated. However, during the on-site investigation the facility was found to be out of compliance with 28 Pa code which pertain to the facility. The following deficiencies were identified during this investigation:
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Plan of Correction
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709.34 (a) (1) 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:
(1) Physical assault or sexual assault by staff or a client.
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Observations
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:(1) Physical assault or sexual assault by staff or a client.
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Plan of Correction
The Project Director will develop and implement policies and procedures to respond to the following unusual incident: Physical assault or sexual assault by staff or client. This will be completed and implemented and a copy of this policy will be added to the facility policy and procedure manual no later than 11/15/2019. |
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
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:(2) Selling or use of illicit drugs on the premises.
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Plan of Correction
The Project Director will develop and implement policies and procedures to respond to the following unusual incident: Selling or use of illicit drugs on the premises. This will be completed and implemented and a copy of this policy will be added to the facility policy and procedure manual no later than 11/15/2019. |
709.34 (a) (3) 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:
(3) 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.
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Observations
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:(3) 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.
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Plan of Correction
The Project Director will develop and implement policies and procedures to respond to the following unusual incident: Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by the facility, for ambulatory services. This will be completed and implemented and a copy will be added to the facility policy and procedure manual no later than 11/15/2019. |
709.34 (a) (4) 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:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Plan of Correction
The Project Director will develop and implement policies and procedures to respond to the following unusual incident: Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. This will be completed and implemented and a copy will be added to the facility policy and procedure manual no later than 11/15/2019. |
709.34 (a) (5) 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:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:(5) Theft, burglary, break-in or similar incident at the facility.
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Plan of Correction
The Project Director will develop and implement policies and procedures to respond to the following unusual incident: Theft, burglary, break-in or similar incident at the facility. This will be completed and implemented and a copy of this policy will be added to the facility policy and procedure manual no later than 11/15/2019. |
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
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Plan of Correction
The Project Director will develop and implement policies and procedures to respond to the following unusual incident: Event at the facility requiring the presence of police, fire or ambulance personnel. This will be completed and implemented and a copy of this policy will be added to the facility policy and procedure manual no later than 11/15/2019. |
709.34 (a) (7) 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:
(7) Fire or structural damage to the facility.
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Observations
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:(7) Fire or structural damage to the facility.
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Plan of Correction
The Project Director will develop and implement policies and procedures to respond to the following unusual incident: Fire or structural damage to the facility. This will be completed and implemented and a copy of this policy will be added to the facility policy and procedural manual no later than 11/15/2019. |
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
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Plan of Correction
The Project Director will develop and implement policies and procedures to respond to the following unusual incident: Outbreak of contagious disease requiring Centers for Disease Control (CDC) notification. This will be completed and implemented and a copy of this policy will be added to the facility policy and procedure annual no later than 11/15/2019. |
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
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:Documentation of the unusual incident.
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Plan of Correction
The Project Director will develop and implement policies and procedures regarding the proper documentation of unusual incidents. This will be completed and implemented and a copy will be added to the facility policy and procedure manual no later than 11/15/2019. |
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
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Plan of Correction
The Project Director will develop and implement policies and procedures regarding the prompt review and identification of the causes directly or indirectly responsible for unusual incidents. This will be completed and implemented and a copy of this policy will be added to the facility policy and procedure manual no later than 11/15/2019. |
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
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:Implementation of a timely and appropriate corrective action plan, when indicated.
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Plan of Correction
The Project Director will develop and implement policies and procedures regarding the implementation of a timely and appropriate corrective action plan, when indicated. This will be completed and implemented and a copy of this policy will be added to the facility policy and procedure manual no later than 11/15/2019. |
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
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include:Ongoing monitoring of the corrective action plan.
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Plan of Correction
The Project Director will develop and implement policies and procedures regarding the ongoing monitoring of an unusual incident corrective action plan. This will be completed and implemented and a copy of this policy will be added to the facility policy and procedure manual no later than 11/15/2019. |
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
After review of the facilities policies and procedures during a complaint investigation, the facility failed to provide policies and procedures in the response to unusual incidents to include: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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Plan of Correction
The Project Director will develop and implement policies and procedures to include a reporting mechanism to ensure the reporting of an unusual incident is in compliance with State and Federal confidentiality laws. This will be completed and implemented and a copy of this policy will be added to the facility policy and procedure manual no later than 11/15/2019.
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709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
During the client interview process it was established that clients were performing work duties for the facility with it not being part of the treatment and rehabilitation plan. It was also confirmed by staff that the facility was unaware this was to be part of the treatment and rehabilitation plan.
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Plan of Correction
The Clinical Supervisor will ensure that all current staff members are notified that any work performed by their clients for the project, at any location, will be considered as a part of their treatment plan and will be documented in an updated treatment plan and included in the next treatment plan review. All current staff will be notified of this policy by way of a memo in their in-box. This policy will also be reviewed during our next staff meeting and will be implemented no later than 11/15/2019. All newly hired staff members will be notified of this policy during their initial training period. The Clinical Supervisor will follow-up to ensure compliance and will be responsible for monitoring and oversight on this policy. |