INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Carbon Monroe Pike Drug and Alcohol Commission, 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client in one out of one applicable record reviewed.
Client #3 was admitted on September 15, 2021 and was administratively discharged on October 20, 2021.
The finding was reviewed with facility staff during licensing process.
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Plan of Correction
Effective 3/1/22, the Outpatient supervisor will review charts of any pending discharges, to make certain there is written notification sent to the client regarding their discharge and that it is also in their chart. |
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 personnel records, the facility failed to inform the Department of an unusual incident within the required three days.
It was discovered that the facility had an unusual incident occur on October 15, 2020 which involved an event requiring staff to contact emergency services for assistance with an individual in their lobby under the influence and requesting rehabilitation services. This individual was in need of emergency services due to their condition and police and ambulance arrived to assist. Upon further inspection it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Anytime fire, police, or ambulance is called to the facility it will be reported to DDAP. The Outpatient supervisor will be responsible to complete the report and Facility Director will be sent all Unusual incident reports to follow up to make sure all required reporting was done. |
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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of seven records reviewed.
Client #2 was admitted on February 24, 2021 and was discharged on January 19, 2022. A treatment plan update was completed on November 8, 2021 and the next update was due no later than January 8, 2022; however there was no update documented in the record at time of the inspection.
Client #4 was admitted on April 7, 2021 and was still active at the time of the inspection. A treatment plan update was completed on October 15, 2021 and the next update was due no later than December 15, 2021; however the next treatment plan update was not completed until February 15, 2022.
Client #5 was admitted on May 17, 2021 and was still active at the time of the inspection. A treatment plan update was completed on November 30, 2021 and the next update was due no later than January 30, 2022; however no treatment plan update was documented in the record at the time of the inspection.
These findings were reviewed with the facility during the licensing process.
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Plan of Correction
Outpatient supervisor will address the 60-day treatment plan update regulatory timeframe with all staff during Outpatient meeting on 3/3/22. The Outpatient supervisor will review charts weekly, to ensure that treatment plan updates are complying with regulatory timeframes. |