INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7, 2020 through January 8, 2020 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 inspection, Pathway to Recovery Counseling and Educational Services 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
During a licensing inspection conducted on January 7, 2020 through January 8, 2020, it was determined that the facility failed to maintain a written fire drill record that included 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
The fire drill record was revised to include whether the fire alarm or smoke alarm was operative. Effective January 2020, the monthly fire drills will be conducted using the firm alarm. Smoke alarms will be checked on a monthly basis as well. Conducting monthly fire drills and maintaining the fire drill records will be the responsibility of the Fiscal Director. The person responsible for ensuring compliance to this regulation will be the President and CEO. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
During a licensing inspection conducted on January 7, 2020 through January 8, 2020, it was determined that the project director failed to prepare, annually update and sign a written manual delineating project policies and procedures.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective January 2020 the project director will annually prepare, update and sign a written manual delineating project policies and procedures. This update will be included in the Annual Report prepared and presented by the President and CEO to the Board of Directors for approval during each June (end of Fiscal Year) Board meeting. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
During a licensing inspection conducted on January 7, 2020 through January 8, 2020, it was determined that project staff failed to notify one client, in writing, of a decision to involuntarily terminate the client's treatment at the project.Client #8 was admitted on October 14, 2019 and involuntarily terminated from treatment on October 22, 2019. This client did not receive written notification of the involuntary termination.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A meeting was held on January 13, 2020 where all clinical and management staff were notified of the protocol for clients who are involuntarily terminated from the program. Specifically, each counselor was instructed to notify, in writing, any client who was involuntarily terminated from the program. A sample letter, which included the appeal process, was provided to all counselors. The Deputy Program Director will be responsible for ensuring compliance to this regulation. |
715.29(4) LICENSURE Exceptions
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation.
(4) The narcotic treatment program shall maintain documentation of the Department 's approval of an exception.
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Observations
A narcotic treatment program is permitted, at the time of application or any time thereafter, to request an exception from a specific regulation. At the time of the onsite annual inspection, from January 7, 2020 through January 8, 2020, the program was found to be providing Buprenorphine services without prior approval from the Department. These findings were reviewed with program staff during the licensing process.
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Plan of Correction
A request for an exception on the use of buprenorphine in a non residential facility was submitted on January 15, 2020 to the Pennsylvania Department of Heath Bureau of Community Program Licensure and Certification. This request was submitted by the President and CEO.
Until and following approval of the exception waiver from DDAP, the Deputy Program Director will ensure compliance of the Chapter 715 regulations for nonresidential facilities for current and new clients seeking buprenorphine treatment through regular chart reviews and weekly meetings with the prescribing doctor and clinicians providing psychotherapy.
We anticipate the corrective action to be completed upon receiving approval for the exception from DDDAP within 90 days of submission of the request or by 3/30/2020.
The President and CEO will be responsible for ensuring that this deficiency does not recur though regular monitoring and compliance with all DDAP regulations and Alerts relative to the use of Buprenorphine in nonresidential facilities.
The request was re-submitted via email on February 14, 2020. We were notified via email on February 18, 2020 at 8:31am
that the request has been received. |