INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 10, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, High Focus Centers 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's February 2024 through December 2024 fire drill logs, the facility failed to prepare alternate exit routes to be used during fire drills.
During the reviewed period, every fire drill conducted had fire drill logs that indicated only the front door was utilized for each drill and there were no alternate exit routes prepared and used during drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor Will train staff to ensure alternate exits are identified and used throughout the year by conducting monthly fire drills with staff.
Executive Director and Clinical supervisor Will review this process in group supervision 2x per month with all staff to ensure alternate exits are identified and used throughout the year during monthly fire drills.
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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 review and update treatment and rehabilitation plans at least every sixty days in two of six applicable client records reviewed.
Client # 1 was admitted on June 26, 2024 and was still active at the time of the inspection. A treatment plan update was completed on September 6, 2024 and the next update was due no later than November 6, 2024; however, the update was not completed until November 14, 2024.
Client # 2 was admitted on August 6, 2024 and was still active at the time of the inspection. The individual treatment plan was completed on August 13, 2024 and the first update was due no later than October 13, 2024; however, the update was not completed until October 24, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor will educate staff on treatment plan update time lines on when to be completed. Executive Director and Clinical Supervisor will do this 2x monthly during group supervision and individual supervision.
Executive Director and Clinical Supervisor will monitor that Staff will complete monthly chart audits to ensure treatment plan updates are being completed during policy timeframes.
Executive Director and Clinical Supervisor will Collaborate 1x monthly with Quality and Compliance department to ensure treatment plan update compliance is being followed.
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