INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8-9, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Beyond Addiction Recovery and Treatment Center 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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705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate toilet and washrooms by exhaust fan or window. The ventilation fan in lavatory B, above the commode, was inoperable.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 4/23/2024, the Project Director can confirm that our contracted maintenance company replaced the exhaust fan in lavatory B.
The Project Director will conduct routine Physical Plant inspections based on the DDAP regulations. This will occur no less than once monthly. All repairs to needed physical plant changes will be fixed/maintained by our contracted maintenance company. |
705.10 (c) (2) (i) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
(i) This fire extinguisher shall meet the requirement of one portable fire extinguisher for a 2,000 square foot area.
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Observations
Based on a physical site inspection, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor.
The fire extinguisher located in the kitchen was not secured to the wall.
This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
As of 4/23/2024, the Project Director can confirm that our contracted maintenance company remounted the fire extinguisher in the kitchen.
The Project Director will conduct routine Physical Plant inspections based on the DDAP regulations. This will occur no less than once monthly. All repairs to needed physical plant changes will be fixed/maintained by our contracted maintenance company. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. 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:
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Observations
Based on a review of residential client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in five out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within seven days of admission.
Client #2 was admitted on January 15, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than January 22, 2024; however, it was not completed until March 20, 2024.
Client #3 was admitted February 15, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than February 22, 2024; however, it was not completed until March 20, 2024.
Client #4 was admitted November 6, 2023, and discharged on November 22, 2023. A comprehensive treatment plan was due no later than November 13, 2024; however, it was not completed until November 22, 2023.
Client #5 was admitted on November 8, 2023, and was discharged on February 1, 2024. A comprehensive treatment plan was due no later than November 15, 2023; however, it was not completed until December 6, 2023.
Client #6 was admitted on January 8, 2024, and was discharged on March 7, 2024. A comprehensive treatment plan was due no later than January 15, 2024; however, it was not completed until January 25, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
After review of this deficiency, the acting Clinical Supervisor is implementing a weekly chart audit to ensure timeliness of documentation. The audits will be conducted weekly and sent to the clinical team for review and completion. The Clinical Supervisor will be tasked with following up with the clinical staff to ensure charts are kept within the guidelines of the policies and procedures. The Chief Clinical Officer will oversee this audit. |
709.52(a)(3) LICENSURE Support service type
709.52. 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 a review of residential client records, the facility failed to document proposed type of support service on individual treatment plans in six out of seven applicable records reviewed.
Client #1 was admitted on January 9, 2024, and was still active at the time of the inspection. The treatment plan was dated January 23, 2024.
Client #2 was admitted on January 15, 2024, and was still active at the time of the inspection. The treatment plan was dated March 20, 2024.
Client #3 was admitted on February 15, 2024, and was still active at the time of the inspection. The treatment plan was dated March 20, 2024.
Client #5 was admitted on November 8, 2023, and was discharged on February 1, 2024. The treatment plan was dated December 6, 2023.
Client #6 was admitted on January 8, 2024 and was discharged on March 7, 2024. The treatment plan was dated January 25, 2024.
Client #7 was admitted on January 15, 2024, and was discharged on March 14, 2024. The treatment plan was dated January 25, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
After review of this deficiency, the acting Clinical Supervisor is implementing a weekly chart audit to ensure timeliness of documentation. The audits will be conducted weekly and sent to the clinical team for review and completion. The Clinical Supervisor will be tasked with following up with the clinical staff to ensure charts are kept within the guidelines of the policies and procedures. The Chief Clinical Officer will oversee this audit. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. 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 residential client records, the facility failed to provide a complete client record, which is to include a discharge summary in two out of four applicable records reviewed. The facility's policy and procedures manual states the discharge summary will be completed within seven days of the discharge date.
Client #4 was admitted on November 6, 2023, and was discharged on November 22, 2023. A discharge summary was due no later than November 29, 2023; however, it was not completed until March 5, 2024.
Client #6 was admitted on January 8, 2024 and was discharged on March 7, 2024. A discharge summary was due no later than March 14, 2024; however, it was not completed until March 18, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
After review of this deficiency, the acting Clinical Supervisor is implementing a weekly chart audit to ensure timeliness of documentation. The audits will be conducted weekly and sent to the clinical team for review and completion. The Clinical Supervisor will be tasked with following up with the clinical staff to ensure charts are kept within the guidelines of the policies and procedures. The Chief Clinical Officer will oversee this audit. |