INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 11, 2022 through January 12, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Northeast Treatment Centers Inc. 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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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection conducted on January 11, 2022, the facility failed to ensure that all the fire extinguishers in the facility were inspected and approved annually by the local fire department or fire extinguisher company. The date of the last inspection for all of the extinguishers located in the facility was December 2020. These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Due to program/building vacancy, the fire extinguisher inspection was overlooked for annual inspection and approval.
The Senior Director will add treatment program to the agency wide facilities management calendar for annual reminder. The Director of Facilities will be responsible for the coordination of all fire extinguisher inspections and approvals.
The facility completed annual fire extinguisher inspection on Monday January 31, 2022. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on an administrative review, the facility failed to conduct unannounced fire drills at least once a month for the months of May 2021 through December 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each program throughout Northeast Treatment Centers has an assigned emergency management coordinator whose responsibility it is to conduct unannounced fire drills and record this event into the program's designated emergency event logs.
Due to program/building vacancy, the emergency management coordinator was not assigned for this program. The Senior Director will assign an emergency management coordinator for this program.
The facility will comply with assignment by 3/1/2022.
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709.62(a)(2) LICENSURE Tx methodology
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(2) Treatment methodology.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop a written plan providing for intake and admission which is to include the treatment methodology for the detoxification level of care.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Director will revise and resubmit written policy to address intake and admission policy to include the treatment methodology for the detoxification level of care.
The Senior Director will complete and submit written plan to the Vice President.
The facility will be in compliance by 3/4/2022. |
709.62(a)(3) LICENSURE Completion Requirements
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(3) Requirements for completion of treatment.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop a written plan providing for intake and admission which is to include the requirements for completion of treatment for the detoxification level of care.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Director will revise and resubmit written policy to address intake and admission policy to include the requirements for completion of treatment for the detoxification level of care.
The Senior Director will complete and submit written plan to the Vice President.
The facility will be in compliance by 3/4/2022. |
709.62(a)(4) LICENSURE Criteria - Discharge/termination
709.62. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop a written plan providing for intake and admission which is to include the involuntary discharge/termination criteria for the detoxification level of care.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Senior Director will revise and resubmit written policy to address intake and admission policy to include the involuntary discharge/termination criteria for the detoxification level of care.
The Senior Director will complete and submit written plan to the Vice President.
The facility will be in compliance by 3/4/2022. |
709.64(b) LICENSURE Promoting treatment
709.64. Project management services.
(b) The project shall develop a written plan that delineates specific service planning and counseling approaches used to promote client interest in participating in necessary treatment, following the detoxification process.
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Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to develop a written plan that delineates specific service planning and counseling approaches used to promote client interest in participating in necessary treatment, following the detoxification process.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will develop a written plan the identifies specific service planning and counseling approaches used to promote client interest in participating in necessary treatment, following the detoxification process.
The facility will be in compliance by 3/11/2022. |