INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 23-24, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Bold Steps of PA 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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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of personnel files, the facility failed to document monthly meetings with the clinical supervisor for the first six months of employment. Employee #2 was hired as a clinical supervisor on June 15, 2022 and was still in that position at the time of the inspection. There was no documentation of monthly meetings having occurred. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will meet with the current Clinical Supervisor quarterly beginning 10/4/20 for documented supervisory sessions. If a new Clinical Supervisor is hired, monthly supervisions with them with be completed and documented the first 6 months by the Executive Director and conducted based on the Clinical Supervisor's experience and education thereafter. Facility will be in full compliance with the standard 10/4/2023. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel files, the facility failed to instruct staff in the use of the fire extinguisher upon employment in seven out of seven staff files reviewed.Employee #1 was hired on December 22, 2022 and was still employed at the time of the inspection. Fire extinguisher training was completed on August 9, 2023. Employee #2 was hired on June 15, 2022 and was still employed at the time of the inspection. Fire extinguisher training was completed on November 11, 2022.Employee #3 was hired on September 6, 2022 and was still employed at the time of the inspection. Fire extinguisher training was completed on August 9, 2023.Employee #4 was hired on April 17, 2023 and was still employed at the time of the inspection. Fire extinguisher training was completed on August 14, 2023. Employee #5 was hired on November 28, 2022 and was still employed at the time of the inspection. Fire extinguisher training was completed on August 9, 2023Employee #6 was hired on February 22, 2023 and was still employed at the time of the inspection. Fire extinguisher training was completed on August 9, 2023Employee #7 was hired on April 27, 2023 and was still employed at the time of the inspection. Fire extinguisher training was completed on August 9, 2023.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will provide training on the use of fire extinguishers to new employees on their first day of employment. Executive Director will document trainings by having the new employee and themselves sign off on a document that verifies that they received the training and placing it in the employee's file. The facility will be in full compliance with this standard on 10/4/23. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of fire drill logs, the facility failed to conduct unannounced fire drills at least once a month. The facility did not conduct fire drills from November 2022 through March 2023 and May 2023. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will schedule monthly, unannounced fire drills with Office Manager. The Office Manager will execute the fire drills by notifying occupants that there is a fire and they must evacuate. Fire drills will be logged monthly by the Executive Director on the Fire Drill Log. Fire drills will be conducted at different times every month. The items included and documented on the log by the Executive Director are Date, Time, Amount of Time to Evacuate, Exit Route Used, number of Clients in Building, number of Clients Evacuated, number of Staff Participating Was the Alarm Activated, were there Any Problems, the Planned Corrective Action, and if the Fire Alarm Operational. The facility will be in full compliance with the standard on 10/4/2023.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel files, the facility failed to ensure all personnel are trained to perform assigned tasks during emergencies in seven out of seven staff files reviewed. Employee #1 was hired on December 22, 2022 and was still employed at the time of the inspection. Emergency training was completed on August 14, 2023. Employee #2 was hired on June 15, 2022 and was still employed at the time of the inspection. Emergency training was completed on November 14, 2022.Employee #3 was hired on September 6, 2022 and was still employed at the time of the inspection. Emergency training was completed on August 14, 2023.Employee #4 was hired on April 17, 2023 and was still employed at the time of the inspection. Emergency training was completed on August 14, 2023. Employee #5 was hired on November 28, 2022 and was still employed at the time of the inspection. Emergency training was completed on August 14, 2023Employee #6 was hired on February 22, 2023 and was still employed at the time of the inspection. Emergency training was completed on August 14, 2023Employee #7 was hired on April 27, 2023 and was still employed at the time of the inspection. Emergency training was completed on August 14, 2023.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will train all new employees to perform assigned tasks during emergencies on the first day of employment and will review and provide a copy of the emergency plan to the new employee for the facility in the policy and procedures manual. The training will be documented by the new employee and Executive Director signing a certificate that says the training was completed and putting the document in the employee file. The facility will be in full compliance with this standard on 10/4/23. |
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
Based on a review of fire drill logs, the facility failed to include whether the fire alarm or smoke detector was operational in all drills conducted during the time period of November 2022 through August 2023. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will test alarm during all fire drills to ensure that it is operational. A column has been added to to the fire drill log to document the operability of the fire alarm during each fire drill. The facility will be in full compliance with the standard by 10/4/2023. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on the review of fire drill logs, the facility failed to set off a fire alarm or smoke detector during each drill conducted during the time period of November 2022 through August 2023. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director submitted exception request and approval was granted for an alternate means of announcing fire drills. Office Manager will announce verbally to occupants of the facility during a fire drill so other occupants of the building will not be disturbed by the alarm. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel files, the facility failed to include annual written staff performance evaluations in one of one applicable personnel file.Employee #2 was a clinical supervisor on June 16, 2022 and was still in that position at the time of the inspection. An annual performance evaluation was due on June 16, 2023; however, it was not completed until August 22, 2023. The finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director will create a document that includes hire dates of all employees and add reminders to facility calendar to ensure that all supervisors complete annual reviews by the date due. The facility will be in full compliance with the standard by 10/4/23. |
709.28 (c) 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.
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Observations
Based on the review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in seven out of ten records reviewed. The client records did not contain a release of information form for the funding source. Facility staff confirmed billing had occurred. Client #2 was admitted on February 9, 2023 and discharged on June 9, 2023.Client #4 was admitted on January 30, 2023 and discharged on May 26, 2023.Client #5 was admitted on March 8, 2023 and discharged on May 26, 2023.Client #6 was admitted on March 13, 2023 and was still active at the time of the inspection. Client #7 was admitted on April 26, 2023 and was still active at the time of the inspection. Client #8 was admitted on March 2, 2023 and discharged on April 8, 2023. Client #10 was admitted on March 9, 2023 and discharged on June 23, 2023. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Release of information form for funding sources has been added to the Electronic Health Record system for the facility. Intake staff have been trained to complete the release of information with the client, give an explanation of the release, have the client sign the release and offer a copy of the release to the client. Clinical Director will be responsible for monitoring compliance and will review releases after all client intakes. Facility will be in full compliance with the standard on 10/4/23. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on the review of outpatient client records, the facility failed to document a preliminary treatment plan in six out of six applicable records reviewed. Client #1 was admitted on January 11, 2023 and discharged on June 8, 2023.Client #2 was admitted on February 9, 2023 and discharged on June 9, 2023. Client #3 was admitted on February 16, 2023 and discharged on July 14, 2023.Client #4 was admitted on January 30, 2023 and discharged on May 26, 2023.Client #6 was admitted on March 13, 2023 and was still active at the time of the inspection. Client #7 was admitted on April 26, 2023 and was still active at the time of the inspection. The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Preliminary Treatment Plan, identified as initial treatment plan in company's electronic health records, was added to forms that need to be completed during client intake. Clinicians have been trained by Executive Director and Clinical Director to complete the preliminary treatment plan during client intake. Clinical Director will be responsible to review client chart after intake to ensure preliminary treatment plan was completed in order to meet compliance. Facility will be in full compliance with the standard on 10/4/23. |
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 a review of outpatient client records, the facility failed to document type and frequency of treatment services on the client's individual treatment plan in seven out of seven applicable records. Client #1 was admitted on January 11, 2023 and discharged on June 8, 2023. The comprehensive treatment plan was dated January 18, 2023. Client #2 was admitted on February 9, 2023 and discharged on June 9, 2023. The comprehensive treatment plan was dated March 3, 2023.Client #3 was admitted on February 16, 2023 and discharged on July 14, 2023. The comprehensive treatment plan was dated February 24, 2023.Client #4 was admitted on January 30, 2023 and discharged on May 26, 2023. The comprehensive treatment plan was dated February 1, 2023. Client #5 was admitted on March 8, 2023 and discharged on May 26, 2023. The comprehensive treatment plan was dated April 6, 2023. Client #6 was admitted on March 13, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was dated April 6, 2023.Client #8 was admitted on March 2, 2023 and discharge on April 8, 2023. The comprehensive treatment plan was dated March 7, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinicians have been trained during a clinical training to include both the type and frequency of treatment services in all comprehensive treatment plans. Clinical Director will review comprehensive treatment plans after the development of the first comprehensive treatment plan for the client, and then every 30 days to ensure compliance with the standard. The facility will be in full compliance with the standard on 10/4/23. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on the review of outpatient client records, the facility failed to document proposed type of support services in the client's individual treatment plan in three out of seven applicable records. Client #2 was admitted on February 9, 2023 and discharged on June 9, 2023. The comprehensive treatment plan was dated March 3, 2023. Client #4 was admitted on January 30, 2023 and discharged on May 26, 2023. The comprehensive treatment plan was dated February 1, 2023. Client #8 was admitted on March 2, 2023 and discharged on April 8, 2023. The comprehensive treatment plan was dated on March 7, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinicians have been trained to always document the proposed type of support services within individual treatment plans. Clinical Director will review individual treatment plans after initial development by clinicians and clients, after updates, and every 30 days to maintain compliance with the standard. The facility will be in full compliance with the standard on 10/4/23. |
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 the review of outpatient client records, the facility failed to update treatment plans at least every 60 days in five out of six applicable records. Client #1 was admitted on January 11, 1023 and discharged on June 8, 2023. A comprehensive treatment plan was completed on January 18, 2023 and an update was due no later than March 18, 2023; however, there was no update documented in the record at the time of the inspection.Client #3 was admitted on February 16, 2023 and discharged on July 14, 2023. A comprehensive treatment plan was completed on February 24, 2023 and an update was due no later than April 24, 2023; however, there was no update documented in the record at the time of the inspection.Client #4 was admitted on January 30, 2023 and discharged on May 26, 2023. A comprehensive treatment plan was completed on February 1, 2023 and an update was due no later than April 1, 2023; however, there was no update documented in the record at the time of the inspection.Client #6 was admitted on March 13, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 6, 2023 and an update was due no later than June 6, 2023; however, it was not completed until June 23, 2023.Client #7 was admitted on April 26, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was completed on June 1, 2023 and an update was due no later than August 1, 2023; however, an update was completed on August 3, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A sharable spreadsheet has been created to inform clinicians when updates are due on their client's treatment plans. Admin will update spreadsheet every Monday, Wednesday and Friday to keep information up to date. Clinicians have been given access to the spreadsheet and trained on how to use it to determine when treatment plans are due. Clinical Director will review spreadsheet daily and follow up with clinicians on treatment plan updates in order to ensure compliance. Facility will be in full compliance with the standard on 10/4/23. |
709.93(a)(8) LICENSURE Client records
709.93. 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:
(8) Case consultation notes.
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Observations
Based on a review of outpatient client records, the facility failed to include case consultation notes in accordance with the facility's policy and procedures manual, which states case consultations should be completed every quarter during the first year and annually thereafter in six out of six applicable records. Client #1 was admitted on January 11, 2023 and discharged on June 8, 2023. A case consultation was due on April 11, 2023; however, there was none documented in the record. Client #2 was admitted on February 9, 2023 and discharged on June 9, 2023. A case consultation was due on May 9, 2023; however, there was none documented in the record. Client #3 was admitted on February 16, 2023 and discharged on July 14, 2023. A case consultation was due on May 16, 2023; however, there was none documented in the record. Client #4 was admitted on January 30, 2023 and discharged on May 26, 2023. A case consultation was due on April 30, 2023; however, there was none documented in the record. Client #6 was admitted on March 13, 2023 and was still active at the time of the inspection. A case consultation was due on June 13, 2023; however, there was none documented in the record.Client #7 was admitted on April 26, 2023 and was still active at the time of the inspection. A case consultation was due on July 26, 2023; however, it was completed on August 10, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Case consultation document was added to the EHR system and clinicians have been trained by clinical director to complete case consultations and document on that form at least once every quarter for each client. Spreadsheet has been created and shared with clinicians so they are aware of the due date on case consults. Clinical Director will review client charts every 30 days to make sure clinicians are in compliance with case consultation standard. Facility will be in full compliance with the standard on 10/4/23. |
709.93(a)(10) LICENSURE Client records
709.93. 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:
(10) Discharge summary.
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Observations
Based on a review of outpatient client records, the facility failed to document a discharge summary in accordance with the facility's policy and procedures manual, which is within seven days of discharge in six out of eight applicable records. Client #1 was admitted on January 11, 2023 and discharged on June 8, 2023. A discharge summary was due on June 15, 2023; however, it was completed on August 3, 2023. Client #2 was admitted on February 9, 2023 and discharged on June 9, 2023. A discharge summary was due on June 16, 2023; however, it was completed on August 11, 2023.Client #3 was admitted on February 16, 2023 and discharged on July 14, 2023. A discharge summary was due on June 21, 2023; however, there was no documentation of one in the client's record. Client #5 was admitted on March 8, 2023 and discharged on May 26, 2023. A discharge summary was due on June 2, 2023; however, it was completed on August 10, 2023. Client #8 was admitted on March 2, 2023 and discharged on April 8, 2023. A discharge summary was due on April 15, 2023; however, it was completed on August 10, 2023. Client #10 was admitted on March 9, 2023 and discharged on June 23, 2023. A discharge summary was due on June 30, 2023; however, it was completed on August 11, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinicians have been trained to develop and document a discharge summary for a client within 7 days of discharge from the facility. Clinical Director will review client charts within 5 days of discharge to ensure discharge summary has been completed by the clinician. Clinical Director is responsible for the oversight to ensure compliance. Facility will be in full compliance with the standard on 10/4/23. |
709.93(a)(11) LICENSURE Client records
709.93. 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:
(11) Follow-up information.
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Observations
Based on the review of outpatient client records, the facility failed to document follow-up information in accordance with the facility's policy and procedures manual in six out of six applicable records. The policy and procedures manual states follow-ups within seven days of discharge for terminated, administratively discharged and clients referred out to another provider. Clients that have not been referred to another provider, follow-ups will be completed within 30 days. Client #1 was admitted on January 11, 2023 and was discharged against facility advice on June 8, 2023. A follow-up was due on July 8, 2023; however, it was completed on August 3, 2023. Client #2 was admitted on February 9, 2023 and was discharged against facility advice on June 9, 2023. A follow-up was due on July 9, 2023; however, it was completed on August 11, 2023. Client #4 was admitted on January 30, 2023 and successfully discharged on May 26, 2023. A follow-up was due on June 26, 2023; however, there was no follow-up documented in the record. Client #5 was admitted on March 8, 2023 and discharged against facility advice on May 26, 2023. A follow-up was due on June 26, 2023; however, it was completed on August 10, 2023.Client #8 was admitted on March 2, 2023 and successfully discharged on April 8, 2023. A follow-up was due on May 8, 2023; however, it was completed on August 10, 2023. Client #9 was admitted on December 16, 2022 and successfully discharged on February 6, 2023. A follow-up was due on March 6, 2023; however, it was completed on April 21, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Administrative staff have been trained on following up with clients who were terminated, administratively discharged or referred to another provider within 7 days and those who have not been referred to another provider that a follow-up should be completed within 30 days. Administrative staff is responsible for completing and documenting client follow up. Clinical Supervisor will review client charts within 5 days of discharge and make sure that client follow-up has taken place by administrative staff if necessary. Clinical Director will review chart again 25 days after discharge if follow up is not due until 30 days post discharge. Facility will be in full compliance with this standard by 10/4/23. |