INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 11, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Freedom Healthcare Services, LLC 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) (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 log for the months of July 2023 through May 2024, the facility failed to prepare alternate exit routes to be used during fire drills. All exits documented were the " front door. "
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide training related to use of alternate routes during monthly fire drills and documentation of those routes. Training information will be maintained on site for review and Director and/or Clinical Supervisor will monitor for on-going compliance as indicated with initials on the completed forms. Staff training will be completed by 8/15/24. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in two of five applicable records. The facility policy and procedure manual indicate a case consultation to occur quarterly for the first year of treatment.
Client #1 was admitted on September 6, 2023 and still active at the time of the inspection. A case consultation was due to occur no later than March 4, 2024, however this was not completed until March 18, 2024.
Client #3 was admitted on December 6, 2023 and still active at the time of the inspection. A case consultation was to occur no later than June 7, 2024, however this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will review and update policies surrounding Case Consultation completion and will update as needed. Clinical Supervisor will review with staff in individual supervision timeliness of case consultation and will monitor for accuracy via reporting from EHR as well as via chart auditing of patient records. Individualized trainings will be completed no later than 8/15/24 and documentation of training content will be maintained on site for review as needed. |
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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in two of four records. The policy and procedure manual indicates follow-up contact must be made within ninety days after discharge.
Client #5 was admitted on November 29, 2023 and was discharged on February 7, 2024. The follow-up contact was due to be completed no later than May 7, 2024, however, this was not completed at the time of the inspection.
Client #6 was admitted on August 14, 2023 and was discharged on September 7, 2023. The follow-up contact was due to be completed no later than December 7, 2023, however, this was not completed until December 12, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will provide training related to patient follow-up and will maintain documentation of training on-site. Facility Director will monitor for on-going compliance with EHR reporting and random discharge chart audits. Training will be completed by 8/15/24. |