INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Crisis Management Services, 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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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the fire extinguisher located in the kitchenette was inspected and approved annually by the local fire department or fire extinguisher company. The date of the last inspection indicated on the fire extinguisher tag was October 2020. This is a repeat citation from the January 4, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The fire extinguisher located in the kitchenette has been replaced with a new fire extinguisher that is fully charged and has been inspected by our contracted fire extinguisher company. This fire extinguisher carries an expiration date of 10/22.
Going forward, a floor plan that includes the location of all five fire extinguishers will be checked by the facility or project director each year to ensure all five fire extinguishers are fully charged and inspected with a current inspection.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 review of the facility's January 2021 through October 2021 fire drill logs, the facility failed to identify, on their fire drill log, the time that the fire drill was conducted in April 2021.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The time of the fire drill was pulled from the Penrose avenue maintenance log on 11/16/21.
Going forward, the project or facility director will transcribe all elements of the fire drill to the final form and the project or facility director will ensure all elements were documented. This will be completed within 24 hours of a fire drill.
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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
Based on a review of client records, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in seven of seven client records reviewed. The project ' s written procedure manual stated that the biopsychosocial assessment would be completed within the first 5 days of a client's admission.Client # 1 was admitted on October 25, 2021 and was still active at the time of inspection. The biopsychosocial assessment was due no later than October 30, 2021; however, the assessment was completed on November 4, 2021.Client # 2 was admitted on October 26, 2021 and was still active at the time of inspection. The biopsychosocial assessment was due no later than October 31, 2021; however, the assessment was completed on November 4, 2021.Client # 3 was admitted on October 29, 2021 and was still active at the time of inspection. The biopsychosocial assessment was due no later than November 3, 2021; however, the assessment was completed on November 5, 2021.Client # 4 was admitted on July 22, 2021 and was discharged on September 1, 2021. The biopsychosocial assessment was due no later than July 27, 2021; however, the assessment was completed on July 29, 2021.Client # 5 was admitted on August 24, 2021 and was discharged on September 30, 2021. The biopsychosocial assessment was due no later than August 29, 2021; however, the assessment was completed on September 3, 2021.Client # 6 was admitted on September 1, 2021 and was discharged on October 25, 2021. The biopsychosocial assessment was due no later than September 6, 2021; however, the assessment was completed on September 10, 2021.Client # 7 was admitted on October 9, 2021 and was discharged on November 8, 2021. The biopsychosocial assessment was due no later than October 14, 2021; however, the assessment was completed on October 17, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy regarding biopsychosocial assessments has been rewritten and placed into the policy and procedure manual. The new policy will read as follows
A complete Biopsychosocial Assessment will be completed on each consumer within the first ten days of treatment. This includes Initial Treatment Plan, Treatment Plan, Psychosocial Assessment, Psychosocial Evaluation, Nursing Assessment, Psychiatric Evaluation, Physical, Lab Work, and a Self-Assessment of client identified problems. This information of past and present problems will be used to formulate their Comprehensive Treatment Plan. If the biopsychosocial is not completed within 10 days of treatment, the Addictions Counselor will document why it was not completed within the timeline.
The facility director will review the new policy with all relevant members of the River's Bend Team by 1/14/22.
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709.28 (c) 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.
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Observations
Based on a review client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven client records reviewed.Client # 4 was admitted on July 22, 2021 and was discharged on September 1, 2021. There was documentation and case management notes on August 28, 2021 and August 29, 2021 that indicated disclosures to a recovery house and another treatment provider during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.Client # 5 was admitted on August 24, 2021 and discharged on September 30, 2021. There was documentation and case management notes on September 15, 2021 and September 27, 2021 that indicated disclosures to two separate treatment providers during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.Client # 6 was admitted on September 1, 2021 and discharged on October 25, 2021. There was documentation and case management notes on October 22, 2021 that indicated disclosures to another treatment provider and a recovery house during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.This is a repeat citation from the January 4, 2021 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The charts found without consents are closed charts and the clients have been discharged. Those charts cannot be corrected however, those charts were reviewed with the clinical team on 11/23/21.
Going forward, the project and facility director will retrain all current staff with regards to the regulations that govern 709.28 ( C ) confidentiality, and will be emphasized and trained during the orientation process of all new staff.
This will be completed by 1/14/22 and then as needed.
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