INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 17, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Holcomb Associates, 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct an unannounced fire drill in each of the following months: December 2017, February 2018, and November 2018 through March 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Support Staff (CSS)Coordinator shall ensure that monthly fire drills are performed and documented and kept in the Environment of Care Log each month. The Clinical Support Staff created a reminder through the Outlook Calendar to ensure that a re-occurring scheduled drill takes place each month. After each drill is performed the CSS Coordinator shall email every staff person in the building the findings of the drill and outline any action steps that need to be followed to ensure a safe and timely exit from the building in the event of a fire. The CSS Coordinator is also a part of the Agency's Environment of Care committee that meets monthly to discuss any issues or barriers arising from monthly fire drills for resolution. The Regional Director will conduct ongoing bi-weekly supervisions with the CSS Coordinator where findings of the fire drills, including timeliness, will be discussed and training provided as needed. |
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
The facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in one of one client record.
Client #1 was admitted on July 19, 2018 and was discharged on March 28, 2019. The written procedure manual states that the master treatment plan must be developed within 30 days from the date of admission; however, the treatment plan was not developed until January 31, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The current staff were re-trained through supervision on the policy that details timeliness of treatment plans. This is a focus of ongoing group supervision. Additionally, each clinician was given a tool to track timeliness of treatment plans for their clients which will be utilized ongoing to avoid any delays in the development of treatment goals with the client. |