INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29 -30, 2020 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, Treatment Trends Inc. Confront 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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709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the policy and procedures manual, the facility failed to document written project personnel policies and procedures to include the utilization of volunteers. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Executive Director and Executive Secretary of Treatment Trends, Inc will review the personnel policies and procedures and include the utilization of volunteers. This will be completed by March 31, 2020 and then disseminated to staff upon approval of the board. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
Based on a review of the policy and procedures manual, the facility failed to document written policies and procedures regarding all medication used by clients. The facility offers Vivitrol to its clients. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Confront Program Director will meet with the COE Project Director and Medical Director to review and write a medication policy in regards to the use and storage of Vivitrol at Confront. This will be completed by March 31, 2020 and reviewed with the staff. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the policy and procedures manual, the facility failed to develop and implement policy and procedures to respond to selling or use of illicit drugs on the premises. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Executive Director and Executive Secretary will review and write a policy and procedure in regards to the selling or use of illicit drugs on the premises. This will be completed by March 31, 2020 and reviewed with staff. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the policy and procedures manual, the facility failed to develop and implement policy and procedures to respond to theft, burglary, break-in or similar incident at the facility. These findings were reviewed with project staff during the licensing process.
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Plan of Correction
Executive Director and Executive Secretary will review and write a policy and procedure in regards to theft, burglary, break in or any similar incident at Treatment Trends, Inc/Confront. This will be completed by March 31, 2020 and reviewed with staff. |