INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 12, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Services of Beaver Valley Inc. 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 a review of personnel information, the facility failed to document supervision notes for the clinical supervisor in one of one personnel records.
Staff #2 was hired as a clinical supervisor on August 1, 2022. There was no documentation of monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment. Meetings were not documented for August, September, October and November 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and Clinical Supervisor have scheduled a minimum of six monthly supervisory meetings beginning 1/23/23. The focus and content of the meetings will be documented by the Executive Director.
The Board of Directors and Executive Director will ensure that monthly supervisor meetings are productive and completed as scheduled. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to maintain facility grounds that are safe and in good repair.
The exterior stairs of the facility to the garden level/project office have a loose stair.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director has notified the Maintenance Department and owner of the building of the loose step 12/22/22. The Maintenance Department is in the process of making the repair.
The Executive Director and the President of the Board of Directors will monitor the progress of the repair. If the repair is not completed within 45 days, the Executive Director and President of the Board will schedule a meeting with the owner of the building to ensure that the repair is completed within 60 days.
The Executive Director will make periodic tours of the physical plant and report any concerns to the owner of the building as soon as possible. The Board of Directors will be notified as well so that their support can be accessed when needed. |
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 a review of personnel records, the facility failed to instruct all staff in the use of fire extinguishers upon employment in two of two personnel records.
Staff #2 was hired as a clinical supervisor on August 1, 2022. There was no documentation of fire extinguisher training in staff record #2.
Staff #3 was hired as a clinical supervisor on October 13, 2022. There was no documentation of fire extinguisher training in staff record #3.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Counselor and Clinical Supervisor will use the available online resources to provide Fire Safety Training. This training will be completed by 1/31/23. In the future the Clinical Supervisor will direct new employees to the online resources for Fire Safety training that can be done in the facility at the time of hire. |
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 a review of personnel records, the facility failed to ensure all personnel on all shifts are trained to perform assigned tasks during emergencies in two of two personnel records.
Staff #2 was hired as a clinical supervisor on August 1, 2022. There was no documentation of emergency training in staff record #2.
Staff #3 was hired as a counselor on October 13, 2022. There was no documentation of emergency training in staff record #3.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director will assign emergency procedure directives regarding appropriate exits, emergency tasks, and meeting spots to ensure the safety of staff and attending clients to the Clinical Supervisor.
The Clinical Supervisor will share these directives with new employees at the time of hire in order to ensure the safety of all personnel involved. |
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.
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Observations
Based on a review of the facility ' s fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.
The monthly fire drill records from December 2021 through November 2022 report the same exit being utilized for all drills.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director, Clinical Director, Counselor, and attending clients have begun using alternate exit routes for fire drills for the fire drill conducted 12/21/22. Each exit used will be documented on each monthly fire drill report.
The Executive Director will be responsible for monitoring the fire drills to make sure that each exit is used randomly on an ongoing basis. |
709.24 (a) (3) 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:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document a policy and procedure which included the timeframe for treatment plan updates.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has changed the Treatment and Rehabilitation Section (709.24) Policy and Procedures manual to note that the Comprehensive Treatment Plans are updated every 60 days. This change will be presented to the Board of Directors for approval at the monthly board meeting on 1/23/23.
The Clinical Supervisor will continue to peruse the Policy and Procedure manual to ensure that this manual is current and is in compliance with DDAP regulations. The Clinical Supervisor will also review random charts to determine that the treatment plan updates are completed in a timely manner. |
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 client records, the facility failed to document the frequency of treatment services on the treatment plan in four of four client records.
The treatment plans documented in client records #1, 2, 3 and 4 did not have documentation of the frequency of treatment services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Counselor has changed the Preliminary Treatment Plan to include the frequency of contact (either weekly or bi-weekly) with the client. This contact has been noted on each succeeding client treatment plan.
A special note has been made in the client records #1, 2, 3, and 4 to document the frequency of contact.
The Clinical Supervisor will review random files to ensure that frequency of contact is noted. |