INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 25, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment & Healing 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that facility heaters that are not permanently mounted or installed are not permitted. A portable space heater was in a counselor's office.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All heating and cooling units, not permanently mounted or installed, have been removed from the building. All staff have been made aware of the regulation, and additional training has been provided and added to the orientation outline for new hires. The onsite supervisor will do weekly building inspections to make sure that no additional events occur.
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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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Staff #3 was hired as a counselor assistant on April 8, 2024, and was still in the position as of the date of the inspection. The fire extinguisher training should have been completed no later than April 15, 2024; however, it was not completed until June 18, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff have been made aware that all new hires must be trained in fire safety within the first 7 days of employment, and then take a review course annually. This timeline has been added to the new hire training packet. The supervisor on site will be responsible for having the new hire complete the training within the allotted time frame. This will then be monitored for compliance by the HR director and the Project Director within 10 days 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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that personnel on all shifts are trained to perform assigned tasks during emergencies.
Employee #3 was hired as a counselor assistant on April 8, 2024, and was still in the position as of the date of the inspection. The fire emergency training should have been completed no later than April 15, 2024; however, it was not completed until June 19, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff have been made aware that all new hires must be trained in emergency preparedness and procedures within the first 7 days of employment, and then take a review course annually. This timeline has been added to the new hire training packet. The supervisor on site will be responsible for having the new hire complete the training within the allotted time frame. This will then be monitored for compliance by the HR director and the Project Director, who will review new hire training logs within 10 days of hire.
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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 the August 18, 2023 through June 11, 2024 fire drill logs, the facility failed to document whether a fire alarm or smoke detector was operative at the time of the drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
All staff have been made aware of the necessity of documenting whether a fire alarm or smoke detector was utilized during fire/emergency drills. A column has been added to the tracking sheet to document this. All staff have been trained in how to conduct and document the drill appropriately. Training for this has also been added to the new hire protocol. The site supervisor will review the fire drill grid monthly to ensure that it is being completed correctly and that drills are occurring.
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709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on the review of client records, the facility failed to document a complete informed and voluntary consent form to release information, which includes specific information disclosured, in one out of seven records reviewed.
Client #4 was admitted on September 1, 2023, and was discharged on May 17, 2024. A release of information form was signed and dated on September 1, 2023, to a family member. This release did not designate the specific information being disclosed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been retrained in the completion of consents, including the designation of specific information to be disclosed. This will be monitored by monthly chart audits, conducted by the site supervision, consisting of 3 randomly selected charts from each clinician for each level of care. If a consent is found to have errors, the clinician will be given 7 days to have contact with the client and correct. The chart will then be re-reviewed within 10 days. If the consent remains invalid, the staff will be supplied with a 1-1 refresher training. If this event occurs 3 or more times, disciplinary action will be taken.
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709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a complete informed and voluntary consent form to release information, which includes a purpose of disclosure, in one out of seven records reviewed.
Client #4 was admitted on September 1, 2023, and was discharged on May 17, 2024. A consent form dated September 1, 2023, to a family member did not designate the purpose of the disclosure.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been retrained in the completion of consents, including the purpose of disclosure. This will be monitored by monthly chart audits, conducted by the site supervision, consisting of 3 randomly selected charts from each clinician for each level of care. If a consent is found to have errors, the clinician will be given 7 days to have contact with the client and correct. The chart will then be re-reviewed within 10 days. If the consent remains invalid, the staff will be supplied with a 1-1 refresher training. If this event occurs 3 or more times, disciplinary action will be taken.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of unusual incident reports and interviews with facility staff, the facility failed to inform the Department of an unusual incident within the required three business day regulatory time frame. The facility had documentation that an unusual incident occurred on February 22, 2024. This incident involved the presence of an ambulance at the facility. The facility did not submit a written unusual incident report to the Department.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been trained in the steps needed in response to an unusual incident. They have been made aware of what constitutes an unusual incident, who to report it to, how to make the report, and within what time frame the report has to be made. These procedures have been expressly written and explained and have been added to all new hire training. When an unusual incident occurs, they are to contact the Project Director immediately. She will then walk them through what forms to complete and submit to DDAP and any relevant insurance companies. A copy of the incident report will be kept in an administrative file and the client record.
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709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in four out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within thirty days intake.
Client #3 was admitted on February 28, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 28, 2024; however, it was not completed until April 5, 2024.
Client #5 was admitted on September 20, 2023, and discharged on February 29, 2024. A comprehensive treatment plan was due no later than October 20, 2023; however, there was not a completed treatment plan in the client record.
Client #6 was admitted on December 15, 2023, and discharged on February 23, 2024. A comprehensive treatment plan was due no later than January 15, 2024; however, it was not completed until February 6, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The timelines in the policy and procedure manual have been reviewed with staff and training has been provided on treatment plan development in a timely manner. This will be monitored by monthly chart audits, conducted by the site supervision, consisting of 3 randomly selected charts from each clinician for each level of care. If a treatment plan is found to be late/overdue, the clinician will be given 7 days to have contact with the client and correct, and a note documenting why it was late placed in the chart. The chart will then be re-reviewed within 10 days. If the treatment plan remains incomplete/unsigned, the staff will be supplied with a 1-1 refresher training. If this event occurs 3 or more times, disciplinary action will be taken.
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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 a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in three out of six applicable client record. The facility's policy states that successfully discharge clients will be contacted within thirty days of discharge. Additionally, the policy notes that unsuccessfully discharged or transferred clients will be contracted within seven days of discharge.
Client #5 was admitted on September 24, 2023, and discharged unsuccessfully on February 29, 2024. A follow-up contact should have been made no later than March 7, 2024; however, there was no documentation of a letter or phone call in the client record.
Client #7 was admitted on April 9, 2024, and was discharged unsuccessfully on May 14, 2024. A follow-up contact should have been made no later than May 21, 2024; however, it was not documented until June 17, 2024.
Client #9 was admitted on June 8, 2023 and transferred on January 8, 2024. A follow-up contact should have been made no later than January 15, 2024; however, it was not documented until January 17, 2024.
This is a repeat citation from the August 29, 2023 licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The timelines in the policy and procedure manual have been reviewed with staff and training has been provided on follow up contact. This will be monitored by monthly chart audits, conducted by the site supervision, consisting of 3 randomly selected charts from each clinician for each level of care. If a follow up contact is found to be late/overdue, the clinician will be given 7 days to have contact with the client and correct, and a note documenting why it was late placed in the chart. The chart will then be re-reviewed within 10 days. If the follow up remains incomplete/unsigned, the staff will be supplied with a 1-1 refresher training. If this event occurs 3 or more times, disciplinary action will be taken.
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