INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. Based on the findings of the on-site inspection, Impact Counseling Services, 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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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical site inspection, the facility failed to secure hard copies of the client records within locked storage containers. The door to the file closet which contained client records was unlocked.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
Clinical Supervisor will educate staff on this and do periodic spot checks and implement 09/28/2021
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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
Based on a review of the facility's policy and procedures manual, the facility failed to document responses to all required unusual incidents. The facility's policy stated, "physical assault by patient" and did not include sexual assault or assaults committed by staff.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director shall develop and implement policies and procedures to respond to the following unusual incidents: Physical assault or sexual assault by staff or a client. Project Director will review and implement 09/28/2021
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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 the facility's policy and procedures manual, the facility failed to document responses to all required unusual incidents. The facility's policy stated, "selling of drugs" and did not include use of illicit drugs.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director shall develop and implement policies and procedures to respond to the following unusual incidents: Selling or use of illicit drugs on the premises. The Project director will revise policies and review with staff and be implemented 09/28/2021
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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
Based on a review of the facility's policy and procedures manual, the facility failed to document responses to all required unusual incidents. The facility's policy did not include "which closes the facility for more than 1 day".
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director shall develop and implement policies and procedures to respond to the following unusual incidents: Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
The project director will review with staff and implement 09/28/2021
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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 the facility's policy and procedures manual, the facility failed to document responses to all required unusual incidents. The facility's policy did not include this regulation.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director shall develop and implement policies and procedures to respond to the following unusual incidents: Event at the facility requiring the presence of police, fire or ambulance personnel.
The project director will review with staff and implement 09/28/2021
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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
Based on a review of the facility's policy and procedures manual, the facility failed to document responses to all required unusual incidents. The facility's policy did not include this regulation.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
For Reporting of unusual incidents The project director shall develop and implement policies and procedures to respond to the following unusual incidents: Fire or structural damage to the facility.
The project Director will review with staff and implement 09/28/2021.
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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 the review of client records, the facility failed to document type and frequency of treatment services on individual treatment and rehabilitation plans in two out of five records reviewed.
Client #1 was admitted on April 15, 2021 and was still active at the time of the inspection. The comprehensive treatment plan was dated April 30, 2021.
Client #7 was admitted on January 15, 2021 and discharged on July 14, 2021. The treatment plans were dated April 5, 2021 and June 5, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will ensure that all individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of: Type and frequency of treatment and rehabilitation services.
The clinical supervisor will train staff on this and will do chart reviews to ensure it is being implemented. this is effective 09/28/2021
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in two out of five records reviewed.
Client #1 was admitted on April 15, 2021 and was still active at the time of the inspection. The treatment plan dated June 30, 2021 indicated group sessions one time per week. There was no documentation of any group session occurring starting on June 30, 2021.
Client #4 was admitted on February 3, 2021 and was still active at the time of the inspection. The comprehensive treatment plan dated March 12, 201 indicated 2.5 hours of individual therapy per month. The client received one hour of individual therapy during the months of June, July, and August 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will train staff on and ensure the implementation of counseling services that are provided according to the individual treatment and rehabilitation plan.
Clinical supervisor will audit client records for compliance and will ensure this goes into effect 09/28/2021
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