INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 21, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Penn Highlands Dubois 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of administrative information for personnel, the facility failed to ensure the project / facility director met the qualifications for the position.
Employee # 1 was hired for the position of project/facility director on October 27, 2020. Employee #1 does meet the educational qualification but does not meet the experiential qualifications for direct service.
The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
Vice President of Penn Highlands Behavioral Health and Drug Abuse Services will be assigned to the Project Director position effective 7/26/21. A review of the 704.5 Qualification for the positions of project director and facility director demonstrates that the Vice President meets the qualifications for the position of project director as outlined in the PA Code 704.5 c(1) -- this action will allow us to comply with this code.
In addition, an exceptions request will be submitted to DDAP seeking a waiver for the 3 years of direct service requirement under 704.5 c(2) regulation. The Vice President of Penn Highlands Behavioral Health and Drug Abuse Services will remain as acting director until the Department of Drug and Alcohol Programs formally accept the exceptions request.
The surveyor clarified for our program the required project director qualifications ? this clarification will allow us to accurately assess project director qualification requirements as outlined in Pa Code 704.5 c(1 ? 3). |
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
Based on a review of administrative information, the facility failed to conduct monthly fire drills. The facility was approved to begin providing services on October 27, 2020. Fire drills were reviewed from November 2020 to July 2021. There was no documentation of a fire drill for April 2021.
The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The fire drill log will be updated to include the Project Director signature ? update to be completed by 8/20/21. A fire drill will be performed monthly by the Project Director or designee. The fire drill log will be reviewed and signed by the Project Director or designee each month to verify that the drill was conducted ? this action will occur starting with the August 2021 fire drill to be completed before 8/31/21. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 a review of the facility fire drill records between November 2020 and July 2021, the facility failed to maintain a written drill documenting the amount of time it took for evacuation, the exit route used, the problems encountered, and whether the fire alarm or smoke detector was operative.
The amount of time it took for evacuation was not documented on the fire drill records between November 2020 and July 2021.
Exit route used was not documented on the fire drill records between November 2020 and July 2021.
Problems encountered was not documented on the fire drill records for January 2021, February 2021, and March 2021.
Whether the fire alarm or smoke detector was operative was not documented on the fire drill records for November 2020, December 2020, February 2021, March 2021, May 2021 and July 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill log will be updated to include date, time, the amount of time it took for evacuation, exit route used, number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative ? update to be completed by 8/20/21.
The fire drill log will be reviewed and signed by the Project Director or designee each month to assure that the drill included all the necessary elements ? this action will occur starting with the August 2021 fire drill to be completed before 8/31/21.
Continued signature requirement will be evaluated at the July 2022 Drug and Alcohol annual policy review. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the facility fire drill records between November 2020 and July 2021, the facility failed to document which alternate routes were used during all fire drills documented.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill log will be updated to include a list of exits to be used to evacuate the office ? update to be completed by 8/20/21.
The fire drill log will be reviewed and signed by the Project Director or designee each month to assure that each month an alternate exit route is used ? this action will occur starting with the August 2021 fire drill to be completed before 8/31/21.
Continued signature requirement will be evaluated at the July 2022 Drug and Alcohol annual policy review. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facility fire drill records between November 2020 and July 2021, the facility failed to document whether a fire alarm or smoke detector was set off for the months of November 2020, December 2020, February 2021, March 2021, May 2021, and July 2021.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill log will be updated to include whether the fire alarm or smoke detector was operative ? update to be completed by 8/20/21.
The maintenance department will set off the fire alarm or smoke detector during the monthly fire drill ? this action will occur starting with the August 2021 fire drill to be completed before 8/31/21.
The fire drill log will be reviewed and signed by the Project Director or designee each month to assure that the fire alarm or smoke detector was set off during each drill ? this action will occur starting with the August 2021 fire drill to be completed before 8/31/21.
In addition, an exceptions request will be submitted to DDAP requesting a waiver for this requirement.
Continued signature requirement will be evaluated at the July 2022 Drug and Alcohol annual policy review. |
711.92(a)(3) LICENSURE Mngt of Treatment Services
711.92. Treatment and rehabilitation services.
(a) The project 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 development, approval and ongoing management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure, the facility failed to document written procedures for the management of treatment/rehabilitation services for clients.
A procedure was presented, but it did not address all services for client, and was missing intake procedures, consent to treatment, histories, psychosocial evaluation, progress notes and record of service.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical director with consultation by project director will update the Treatment and Rehabilitation Services policy and written procedures for the development, approval, coordination and ongoing management of client treatment and rehabilitation services The elements added to this policy and procedure include processes addressing referrals, intake and admission procedures, client orientation, consent to treatment, histories, physical examination, psychosocial evaluations, progress notes and record of service. The update will include who completes and when each item is completed.
This policy/procedure update will be completed by 8/6/2021.
Ongoing this policy and related procedures will be reviewed annually by the Project Director during the annual drug and alcohol policy review process.
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711.93(c)(1)(i) LICENSURE Confidentiality - Client Identity/Records
711.93. Client records.
(c) Confidentiality.
(1) A written procedure shall be developed by the project director which complies with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(i) Confidentiality of client identity and records.
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Observations
Based on a review of administrative information, the facility failed to document a written procedure for 255.5. A confidentiality procedure was presented, but it did not address 255.5.
The findings have been reviewed with the facility staff during the inspection.
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Plan of Correction
The project director in consultation with the Penn Highlands Compliance Director will update the Confidentiality policy to comply with Pa Code 255.5, Projects and coordinating bodies: disclosure of client-oriented information. The updated policy will address confidentiality of client identity and records including disclosure, restrictions, record transfer and coordinating bodies.
The policy update will be completed by 8/6/2021.
Ongoing this policy will be reviewed and approved annually by the Project Director during the annual drug and alcohol policy review process. |