INITIAL COMMENTS
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This report is a result of an on-site unannounced follow up licensure inspection conducted on July 17, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Providence Treatment 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) (v) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on July 17, 2023, the facility failed to ensure to light interior exits and stairs at all times.
The stairway leading to the second exit on the side of the building was not lit at the time of the inspection. The facility was utilizing solar lights that only come on when the natural light changes in that area.
This is a repeat citation from the February 13, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A maintenance request was submitted to the commercial landlord to modify the existing overhead lighting from light sensor mode to permanent lighting mode.
The commercial landlord confirmed receipt of the maintenance request from the licensee. The expected completion date is 10/31/23. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a request for client records separated by type of service offered by the facility, the facility failed to have a data collection and recordkeeping system developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
The facility was unable to identify a client ' s admission and discharge date from one service to the next. There was no separation of the admission to partial hospitalization and discharge date prior to starting the outpatient service. The admission date started at intake and the client was not listed as discharged until the last day of service all together. The system also did not identify clients according to which licensed facility they are billed as clients for. During a review of a list of reported active clients, many were identified as clients from different states or different locations. The facility was unable to identify what clients were actually listed at this license.
This is a repeat citation from the February 13, 2023 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
1. Facility Director enhanced our current data collection and recordkeepiing spreadsheet to further track the assignment between 2 licensed facilities and the transfer of care between the 2 facilities.
2. Current recordkeeping spreadsheet has been updated as of 9/15/23 to include the assignment of licensed office, date of transfer of care and billing location where the service is received.
3. Facility Director conducted a training with administrative support staff on 9/15/23 about the data entry and accuracy of the client's information on our record keeping spreadsheet.
4. Facility Director will perform monthly audit of the data collection spreadsheet to ensure the accuracy of our client's information including assigned facility where the service is received, any transfer of care dates between 2 facilities, and the billing location where the service is received.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of the client records, the facility failed to have written documentation that individual training and rehabilitation plans were developed with the client within three weeks of admission in three applicable records reviewed.
Client #1 was admitted on June 1, 2023 and was current at the time of the inspection. Client #1 had a treatment and rehabilitation plan dated June 11, 2023; however, there was no written documentation it was created with the client.
Client #2 was admitted on May 24, 2023 and was current at the time of the inspection. Client #2 was to have a treatment and rehabilitation plan by June 16, 2023; however, there was not one documented until June 22, 2023.
Client #4 was admitted on May 31, 2023 and was current at the time of the inspection. Client #4 had a treatment and rehabilitation plan dated May 31, 2023; however, there was no written documentation it was created with the client.
This is a repeat citation from the February 13, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
1. Facility Director obtained documentation from client #1 and # 4 regarding their participation in the development of their treatment plan on 7/18/23.
2. Facility Director conducted a training with all clinical staff and administrative support staff about recordkeeping and treatment plan documentation on 7/21/23.
3. Facility Director will monitor due dates of all treatment plans weekly and discuss with all clinicians.
4. facility Director will perform monthly audit in our EMR system to confirm treatment plan compliance and treatment plan documentation. |