INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 9, 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 all staff in the use of fire extinguishers upon staff employment in two of five applicable personnel records reviewed.
Employee #4 was hired as a counselor on May 13, 2024. The fire extinguisher training was due upon the employee's employment; however, the training was provided on September 25, 2024.
Employee #5 was hired as a counselor on August 19, 2024. The fire extinguisher training was due upon the employee's employment; however, the training was provided on September 25, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new staff will have Fire Safety training within the first 7 days of hire. The Training and Development Team will include this training on the New Hire Onboarding Training Checklist and this training will auto populate in the training system during the first week of hire. The Executive Clinical Director will run a transcript of completed trainings at the conclusion of the new hire's first week to ensure completion of this and all required trainings. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's December 2023 through September 2024 fire drill logs, the facility failed to conduct fire drills at different times of the day and on different staffing shifts.
The facility's hours of operation were posted as Monday through Thursday from 9:00AM to 9:00PM, and Friday from 9:00AM to 5:00PM. All of the fire drills, completed during the reviewed period, were conducted at or prior to 3:30PM. There were no fire drills conducted during the evening/night hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director and the Clinic Director will ensure that fire drills are conducted monthly at different times of the day, different days of the week, and on different staffing shifts to cover the operational hours of the site. |
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 review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of one applicable client record reviewed.
The policy and procedure manual stated that a client who is absent without leave (AWOL) is considered to be grounds for termination/discharge. Per the policy, an AWOL client is someone who does, or does not inform staff he or she chooses to terminate treatment and does so without being provided with a written aftercare recommendation meets involuntary termination/discharge criteria.
Client #5 was admitted on April 10, 2024 and was still active at the time of inspection. The last contact between facility staff and the client was on April 15, 2024. There was no additional documentation, in the record, regarding outreach attempts or the current status of the client. The facility failed to follow their discharge procedures for this client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director will review proper outreach and discharge procedures with clinical Team during weekly clinical rounds. Executive clinical director will also review in individual supervision. Executive Clinical Director will randomly pull chart to audit and ensure outreach attempts are properly documented, and that discharge documentation and procedures are conducted within the required time period. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of the on a release of information form in one of eight client records reviewed.
Client #5 was admitted on April 10, 2024 and was active at the time of the inspection. There was a release of information form for treatment, payment, and healthcare operations dated April 10, 2024; however, the release form did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Clinical Director will train and review with all clinicians and office managers the process of completing all release of information documents and ensuring the client's signature is visible at the time of intake. Charts will be audited to ensure documentation is completed properly and completely by the Executive Clinical Director or the Clinic Director on a monthly basis. |
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 five of five applicable client records reviewed.
Client #1 was admitted on February 29, 2024 and was discharged on September 19, 2024. The individual treatment and rehabilitation plan was completed on May 7, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #2 was admitted on March 15, 2024 and was discharged on June 18, 2024. The individual treatment and rehabilitation plan was completed on March 26, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #7 was admitted on August 26, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 12, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #8 was admitted on July 25, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 7, 2024; however, the plan did not include the type and frequency of treatment and rehabilitation services.
Client #9 was admitted on August 12, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 16, 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
Executive Clinical Director will review proper treatment plan documentation with clinical Team during weekly clinical rounds. Executive clinical director will also review in individual supervision. Executive Clinical Director will randomly pull charts to audit monthly and ensure that all treatment plans include the type and frequency of treatment and rehabilitation services. |
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 four of five applicable client records reviewed.
Client #1 was admitted on February 29, 2024 and was discharged on September 19, 2024. The individual treatment and rehabilitation plan was completed on May 7, 2024; however, the plan did not include documentation of any proposed type of support services.
Client #7 was admitted on August 26, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 12, 2024; however, the plan did not include documentation of any proposed type of support services.
Client #8 was admitted on July 25, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 7, 2024; however, the plan did not include documentation of any proposed type of support services.
Client #9 was admitted on August 12, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 16, 2024; however, the plan did not include documentation of any proposed type of support services.
This is a repeat citation from the December 7, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director will review proper treatment plan documentation to include support services (ie. AA/NA meetings) with clinical Team during weekly clinical rounds. Executive clinical director will also review in individual supervision. Executive Clinical Director will randomly pull charts to audit monthly and ensure that all treatment plans include the documentation of any support services for the client. |
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 three of three applicable client records reviewed.
Client #1 was admitted on February 29, 2024 and was discharged on September 19, 2024. The individual treatment and rehabilitation plan was completed on May 7, 2024 and the first update was due no later than July 7, 2024; however, the update was not completed prior to discharge.
Client #2 was admitted on March 15, 2024 and was discharged on June 18, 2024. The individual treatment and rehabilitation plan was completed on March 26, 2024 and the first update was due no later than May 26, 2024; however, the update was not completed prior to discharge.
Client #8 was admitted on July 25, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on August 7, 2024, and the first update was due no later than October 7, 2024; however, the update was not completed as of the date of the inspection.
This is a repeat citation from the December 7, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director will review proper treatment plan procedures with clinical Team during weekly clinical rounds. Executive clinical director will also review in individual supervision. Executive Clinical Director will randomly pull chart to audit and ensure Outpatient treatment Plans are being updated every 60 days. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in one of three applicable client records reviewed.
Client #2 was admitted on March 15, 2024 and was discharged on June 18, 2024. The individual treatment and rehabilitation plan dated March 26, 2024 indicated the client was to receive weekly services. However, there was no documented weekly services provided from May 12, 2024 through the discharge date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director will review scheduling and maintaining treatment protocol with clinical Team during weekly clinical rounds. Executive clinical director will also review in individual supervision. Executive Clinical Director will randomly pull chart to audit and ensure that clients are being provided the services which are outlined in the client's treatment plan. |
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 two of two applicable client records reviewed.
Client #2 was admitted on March 15, 2024 and was discharged on June 18, 2024. There was no follow-up information documented in the record at the time of the inspection.
Client #3 was admitted on May 13, 2024 and was referred to a higher level of care on June 3, 2024. There was no follow-up information documented in the record at the time of the inspection.
This is a repeat citation from the December 7, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director will review and revise existing Follow-Up policy to add specifics of staff responsibility. Staff will be trained to follow up 30-, 60- and 90-days post discharge from substance use, co-occurring or intensive outpatient level of treatment. The Executive Clinical Director will train all staff to comply with updated Follow-Up policy. Executive Clinical Director to randomly pull chart audits to ensure policy is being followed. |