INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 18, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Glenbeigh Center of Erie 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 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
The facility failed to ensure the exits from the facility were unobstructed. At the time of the inspection, October 18, 2017, the second exit from the basement level was blocked by a trash can and debris. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Daily on days of business the client representative or the safety director at the facility will do a walk through of the building and ensure all exits are not blocked. The fire drill/safety check list for the facility will now contain an additional line to check all exits and will be signed off by the facility safety director. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
The facility failed to maintain a client census under the maximum capacity of 70.During the annual inspection on October 18, 2017, the client census, and the total number of clients on the caseload list was 86 clients, which exceeds the maximum allowed.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
A request for increase in capacity was submitted to the DDAP Licensure Division. The request of an increase to 105 clients will be compliant with maximum caseloads determined by the licensing board by facility clinicians. Capacity will be monitored by facility director and if close to exceeding the newly requested capacity in the future a new request will be submitted and appropriate staff will be hired.In the future, the program director will ensure that the facility census will not exceed maximum approved capacity. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document written acknowledgement by clients that they have been notified of those rights in three of seven client records reviewed on October 18, 2017. Client records #3, #5 & #6 did not include the documentation.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Although clients were notified their signatures were not documented. In order to ensure this no longer happens the orientation checklist was made electronic and added to the electronic record. Clients must sign electronically when orientation is discussed upon intake. Intake staff will monitor this and it will be double checked by the facility director. A training was held informing staff of the new changes. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
The facility failed to disclose to the client the criteria for admission, treatment, completion and discharge in three of seven client records reviewed on October 18, 2017. Intake procedures did not include documentation of client of criteria for admission, treatment, completion and discharge for client record #3, #5, and #6These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Although clients were notified their signatures were not documented. In order to ensure this no longer happens the orientation checklist was made electronic and added to the electronic record. Clients must sign electronically when orientation is discussed upon intake. Intake staff will monitor this and it will be double checked by the facility director. A training was held informing staff of the new changes. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
The facility failed to document the client orientation in three of seven client records reviewed on October 18, 2017. Intake procedures did not include documentation of project policies, hours of operation, fee schedule and services provided for client record #3, #5, and #6These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Although clients were notified their signatures were not documented. In order to ensure this no longer happens the orientation checklist was made electronic and added to the electronic record. Clients must sign electronically when orientation is discussed upon intake. Intake staff will monitor this and it will be double checked by the facility director. A training was held informing staff of the new changes. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
The facility failed to complete psychosocial evaluations in three of seven client records reviewed on October 18, 2017.Client records #2, #3, and #6 did not contain a psychosocial evaluation.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical staff currently use a check list of actions required to properly admit a client to our agency upon beginning treatment. A line documenting the need to perform the assessment was added to this checklist. The facility director will check to ensure the pyschosocial evaluation is completed and documented. The office coordinator will double check that it was completed. Staff training took place explaining the addition to the check list and the need to complete the assessment. |