INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute, 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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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 a review of the facility fire drill log for the months of August 2024 through January 2025, the facility failed to provide documentation of any fire drills being conducted during this period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 2/21/2025, the Director of Compliance trained the newly hired Director of Outpatient on the requirement to conduct monthly fire drills. The Director of Outpatient will conduct fire drills at least once a month and this will be monitored through site visits for 100% compliance by the Director of Compliance. |
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 client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in three of three applicable records.
Client #1 was admitted to outpatient on September 16, 2024 and was discharged on December 16, 2024. A treatment and rehabilitation plan was developed on September 18, 2024. A treatment and rehabilitation plan update was due no later than November 18, 2024, but was not completed.
Client #2 was admitted to outpatient on October 10, 2024 and was discharged on January 12, 2025. A treatment and rehabilitation plan was developed on October 13, 2024. A treatment and rehabilitation plan update was due no later than December 13, 2024, but was not completed.
Client #3 was admitted to outpatient on October 22, 2024 and was discharged on January 12, 2025. A treatment and rehabilitation plan was developed on October 25, 2024. A treatment and rehabilitation plan update was due no later than December 25, 2024, but was not completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The newly hired Director of Outpatient was trained/educated by the CEO on the timely completion of chart documentation at their CEO-OP meeting on 2/26/25. The Director of Outpatient also met with the Director of Clinical Services and Lead Counselor at St Joseph Institute on 2/26-2/28 for training on the EMR. Once the outpatient program begins, the Director of Outpatient will audit the charts on a weekly basis for 3 months to ensure 100% compliance. After the 3 months, compliance will be monitored through monthly chart audits |
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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure in two of four records.
The policy and procedure indicates follow-up contact must be made within seven days after discharge.
Client #2 was admitted to outpatient on October 10, 2024 and was discharged on January 12, 2025. Follow-up contact was to be made no later than January 19, 2025, but was not documented in the client record.
Client #4 was admitted to outpatient on November 4, 2024 and was discharged on January 6, 2025. Follow-up contact was to be made no later than January 13, 2025, but was not documented in the client record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The newly hired Alumni Coordinator was trained on 2/21/2025 by the Director of Business Development on the requirement to follow-up within the facility's policy of 7 days of discharge. Once the Outpatient program begins, the Director of Business Development will monitor charts for 100% compliance by monthly chart audits.
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