INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 9, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Step-By-Step Support, 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:
|
Plan of Correction
|
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
|
Observations
Based on observation, the facility failed to ensure exits from the facility were unobstructed. The second exit was blocked by two chairs.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The plan of correction is we moved the chair (obstruction) from the second exit. The second exit will remain free from Obstruction such as chairs or any other obstruction that would interfere with the exit. SBSS staff/Director will monitor the second exit daily to make sure it's not blocked when we arrive in the morning and when we leave in the pm.
|
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.
|
Observations
Based on a review of the facility fire drill records between September 2021 and January 2022, the facility failed to document which alternate routes were used during fire drills. Each of the fire drills reviewed documented the front exit was used as the exit.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 2-11-22 the Office Manager will revised fire drill logs to implement alternate routes from the front exit to the rear exit. The office Manager will check fire drill logs monthly to make sure alternate exits are used and documented), The new revised fire drill alternative will be documented monthly and monitored by the Office Manager. |
709.24 (a) (4) 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:
(4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
|
Observations
Based on a review of the policy and procedures, the facility failed to provide the written procedure for outgoing referrals.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 2-11-22 The policy and procedures will be revised to include the procedure for outgoing referrals. The office manager created an outgoing referral form which is to be used and documented by counselors and placed in client files. Will be included in the intake process which will state the date of the referral, the outgoing referral made, and what the referral will be used for. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
|
Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent that included the name of the person, agency, or organization to whom disclosure was to be made, in two of four client records.
Client #1 was admitted on October 28, 2021 and was still a client at the time of the inspection. A release of information, with the purpose of funding, was signed by the client on October 28, 2021 but did not document the name of the person, agency, or organization to whom the information was to be released.
Client #3 was admitted on February 8, 2022 and was still a client at the time of the inspection. A release of information with the purpose of " coordination of care " , was signed by the client on February 8, 2022, but did not document the name of the person, agency, or organization to whom the information was to be released.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
On 2-21-22 Plan of correction for Client # 1 and Client # 3 counselor will ensure all future release of information forms will include the person, agency, or organization), The counselor will ensure that the name of the agency, person, or organization will be included. Counselors will review their client files on a monthly basis and ensure all proper consents are signed and filled out properly monitored. The counselor will correct the informed consent form by providing the person place or organization
to whom the releases will be released. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
|
Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent that included the date, event, or condition upon which the consent will expire in two of four client records.
Client #2 was admitted on November 12, 2021 and was still a client at the time of the inspection. A release of information to a funding source was signed by the client on November 12, 2021 but did not include the date, event, or condition upon which the consent will expire.
Client #3 was admitted on February 8, 2022 and was still a client at the time of the inspection. A release of information to a funding source was signed by the client on February 8, 2022, but did not include the date, event, or condition upon which the consent will expire. A release of information signed on February 8, 2022, did not include the date, event, or condition upon which the consent will expire.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 2-21-22 Client # 2, the office manager updated the consent forms to read that the expired date on the release consent form will expire 1 year from the date of signature.
the counselor will have client # 2 sign a new consent that indicates the expiration date.
In the future counselors will ensure that all clients sign consents which include expiration dates.
Counselors will review client files on a monthly basis to ensure all consents include expiration dates and all proper documentation is in the files. |
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.
|
Observations
Based on a review of client records, the facility failed to document the review and update of treatment and rehabilitation plans at least every 60 days in two of two client records.
Client #1 was admitted on October 28, 2021 and was still a client at the time of the inspection. The individual treatment plan was completed on October 28, 2021. A treatment plan update was due to be completed on December 28, 2021 and was not documented.
Client #2 was admitted on November 12, 2021 and was still a client at the time of the inspection. The individual treatment plan was completed on November 12, 2021. A treatment plan update was due to be completed on January 12, 2022 and was not documented.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 2-21-22 for client #1 and client # 2, the Office manager created a treatment plan update and will be used in the client's chart every 60 days.
In the future, the Counselors will be responsible for making sure treatment plan updates are recorded in their client's files 60 days from the date the treatment plans are developed.
Counselors are responsible to review their client files on a monthly basis to ensure all proper documentation is in place.
The facility director will conduct random record reviews to ensure treatment plan updates are up to date. |