INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Forge Health 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 (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 staff in the use of fire extinguishers upon staff employment in three of six personnel records reviewed.
Employee #3 was hired as a counselor on April 1, 2024. The fire extinguisher training was due upon employment; however, the training was completed on October 10, 2024.
Employee #4 was hired as a counselor on June 24, 2024. The fire extinguisher training was due upon employment; however, the training was completed on October 8, 2024.
Employee #6 was hired as a counselor on May 13, 2024. The fire extinguisher training was due upon employment; however, the training was completed on October 8, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Forge Health has included the "Fire Extinguisher Training" onto the agencies "onboarding checklist". The "onboarding checklist" is an itemized document that outlines mandatory trainings that will occur withing the first week (7 days) of hire. The onboarding checklist is signed by both the new hired employee and Clinical Director and/or Executive Clinical Director, and will be filed away into the employee's records file. Executive clinical director will ensure this is implemented at this site and will be implemented effective 10/24/24 |
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 develop an individual treatment and rehabilitation plan with the client in+ two of six applicable client records reviewed.
Client #3 was admitted on January 19, 2024 and was discharged on April 26, 2024. The facility obtained DDAP licensure on February 28, 2024 and was transitioned to receiving substance use disorder services on that date. There was no documentation indicating an individual treatment and rehabilitation plan for substance use disorder was completed prior to discharge.
Client #4 was admitted on February 15, 2024 and was discharged on June 26, 2024. The facility obtained licensure on February 28, 2024 and was transitioned to receiving substance use disorder services on that date. There was no documentation indicating an individual treatment and rehabilitation plan for substance use disorder was completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be given to clinical staff in order to identify and appropriately develop treatment and rehabilitation plans reflective of presenting issues within 30 days of admission. Training will be provided by the Clinical Director and/or Executive clinical director. Treatment plans will be discussed with clinical staff during weekly clinical supervisions, and treatment plan review periods, to ensure compliance. Compliance Manager along with Executive Clinical Director will ensure the corrective action is implemented |
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 type and frequency of treatment and rehabilitation services on the client's individual treatment and rehabilitation plan in four of four applicable client records reviewed.
Client #2 was admitted on February 14, 2024 and was discharged on April 29, 2024. The individual treatment and rehabilitation plan was completed on March 3, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #5 was admitted on July 15, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 30, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #6 was admitted on July 10, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 31, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #7 was admitted on July 30, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 14, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be given to clinical staff in order to identify and appropriately document type and frequency of treatment and rehabilitation services on the treatment plan. Training will be provided by the Clinical Director and/or Executive clinical director. Treatment plan documentation will be discussed with clinical staff during weekly clinical supervisions, and treatment plan review periods, to ensure compliance. Clinical supervision will be provided by the Clinical Director and/or Executive Clinical Director. Compliance Manager along with Executive Clinical Director will also ensure the corrective action is implemented |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the client's individual treatment and rehabilitation plan in two of four applicable client records reviewed.
Client #2 was admitted on February 14, 2024 and was discharged on April 29, 2024. The individual treatment and rehabilitation plan was completed on March 3, 2024; however, the plan did not include documentation of any proposed type of support services.
Client #6 was admitted on July 10, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 31, 2024; however, the plan did not include documentation of any proposed type of support services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be provided to clinical staff to identify/explore and appropriately document supportive services upon admission and in treatment plans that are conducive to recovery. Executive Clinical Director and Clinical Director will provide training as well as review charts in weekly supervision to ensure implementation. Compliance manager and Executive clinical director will ensure corrective action is implemented. |
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 ensure treatment and rehabilitation plans were reviewed and updated at least every sixty days in one of three applicable client records reviewed.
Client #5 was admitted on July 15, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on July 30, 2024 and the first update was due no later than September 30, 2024; however, the update was not completed as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Training will be given to clinical staff in order to conduct and appropriately document treatment and rehabilitation plan reviews every 60 days. Training will be provided by the Clinical Director and/or Executive clinical director. Treatment plans will be tracked by the clinical director and discussed with staff during weekly clinical supervisions, and treatment plan review periods. Compliance Manager along with Executive Clinical Director will ensure the corrective action is implemented |
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 maintain a complete client record, which is to include the documentation of follow-up information, in three of three applicable client records reviewed.
Client #2 was admitted on February 14, 2024 and was discharged on April 29, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client #3 was admitted on January 19, 2024 and was referred to a higher level of care on April 26, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client #4 was admitted on February 15, 2024 and was discharged on June 27, 2024. There was no follow-up information documented in the record at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager and clinical director have begun tracking discharged clients with a spread sheet and are providing outreach within 90 days of the discharge date. Compliance manager and Executive clinical director will be ensuring corrective action is implemented. |