INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2021 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, WES Corporation was found not 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on review of personnel records on January 28, 2021, the facility was unable to provide a sufficient number of staff persons trained in CPR certification onsite during the project's hours of operation.
These findings were reviewed with facility staff during the licensing process.
This was a repeat citation from a licensing inspection held on January 29, 2020.
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Plan of Correction
All staff shall be trained in CPR by 3/1/2021. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on review of three out of seven client records on January 28, 2021, the project failed to include documentation of the clients being notified that the project may not discriminate in the provision of services on the basis of ethnicity, marital status, or creed.
These findings were reviewed with project staff during the licensing process.
This is a repeat citation from the licensing inspection on January 19, 2020.
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Plan of Correction
The client rights form shall be updated to indicate that the project may not discriminate in the provision of services on the basis of ethnicity, marital status or creed. |
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 seven client records on January 28, 2021, treatment and rehabilitation plans were not updated at least every 60 days.
Client #1 was an active client at time of inspection. A comprehensive treatment plan was completed 2/18/20 and the next update was due no later than 4/18/20; however was not completed until 5/4/20. The next update was due no later than 7/4/20; however was not completed until 11/6/20. There was an update completed on 11/20/20 with the next due no later than 1/20/21; how-ever was not completed at the time of the inspection.
Client #2 was an active client at time of inspection. A treatment plan update was completed 3/5/20 and the next update was due no later than 5/5/20; however, was not completed until 5/21/20. The next update was due no later than 7/21/20; however, was not completed until 10/28/20. The next update was due no later than 12/28/20 and was not completed at the time of the inspection.
Client #3 was an active client at time of inspection. A treatment plan update was completed 2/6/20 and the next update was due no later than 4/6/20; however was not completed until 4/10/20. There was a treatment plan update completed on 6/9/20 with the next due no later than 8/9/20; however was not completed until 11/13/20. The next update was due no later than 1/13/21 was not completed at the time of the inspection.
Client #4 was an active client at time of inspection. A treatment plan update was completed 5/20/20 and the next update was due no later than 7/20/20; however, was not completed until 10/13/20. The next update was due no later than 12/13/20; how-ever was not completed until 12/29/20.
Client #5 was admitted on 10/23/19 and was discharged 11/19/20. A treatment plan update was completed on 3/30/20 and the next update was due no later than 5/30/30; however, was not completed until 6/18/20. The next was completed on 8/17/20 and the next was due no later than 10/17/20; how-ever was not completed at the time of the inspection.
Client #6 was admitted on 1/21/20 and was discharged 11/19/20. A treatment plan was completed 5/20/20 and the next update was due no later than 7/20/20; however, the next update not completed at the time of the inspection.
Client #7 was admitted on 9/24/19 and was discharged 2/5/20. Client #7 had only on treatment plan completed on 10/11/19. No updates were completed at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment and rehabilitation plans of all clients shall be updated by 3/1/2021. Program Director and Quality Management Director shall conduct weekly chart reviews of each client chart to
ensure that all client plans are updated every 60 days. |