INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Synergy Treatment LLC 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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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of six personnel records and the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to demonstrate that a sufficient number of staff persons had CPR certification as only one full-time staff member was certified in CPR and First Aid December 2023 through June 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations will audit trainings annually and ensure that the sufficient number of staff has obtained CPR certification. Since June 2024 as stated the facility has been in compliance with a sufficient number of staff persons certified. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of six personnel records, the facility failed to ensure that each applicable staff member was trained to perform assigned tasks during emergencies prior to being on shift.Employee # 1 was hired as the Project and Facility Director on November 1, 2023 and is current in that position. Employee # 1 began working shifts on November 1, 2023; however, the record did not contain documentation that the employee was trained to perform assigned tasks during emergencies.Employee # 2 was hired as a counselor on December 19, 2023 and is current in that position. Employee # 2 began working shifts on December 19, 2023; however, the record did not contain documentation that the employee was trained to perform assigned tasks during emergencies.Employee # 3 was hired as a counselor on May 28, 2024 and is current in that position. Employee # 3 began working shifts on May 28, 2024; however, the record did not contain documentation that the employee was trained to perform assigned tasks during emergencies.Employee # 4 was hired as a counselor on May 28, 2024 and is current in that position. Employee # 4 began working shifts on May 28, 2024; however, the record did not contain documentation that the employee was trained to perform assigned tasks during emergencies.Employee # 5 was hired as a counselor on April 16, 2024 and is current in that position. Employee # 5 began working shifts on April 16, 2024; however, the record did not contain documentation that the employee was trained to perform assigned tasks during emergencies.Employee # 6 was hired as a counselor assistant on May 20, 2024 and is current in that position. Employee # 6 began working shifts on May 20, 2024; however, the record did not contain documentation that the employee was trained to perform assigned tasks during emergencies.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations held an all staff training on August 6, 2024, to ensure that each applicable staff member is aware of assigned tasks during emergencies.
The onboarding documentation was updated to include this training during orientation. This was added to the document "Orientation Checklist" in HR files for each hire.
The Director of Clinical Operations will ensure this is implemented by periodically checking new hires for the next 6 months. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the January 2024 through June 2024 fire drill logs, the facility failed to document the amount of time to evacuate, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative during each drill conducted.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Fire Drill Log was edited on August 6, 2024, by the Director of Clinical Operations to accurately reflect requested information to be in compliance. All fire drills moving forward will have on the document the amount of time to evacuate, the exit route used, the number of persons in the facility at the time of the drill, problems encountered, and whether the fire alarm or smoke detector was operative during each drill conducted.
The Director of Clinical Operations will ensure this new form is utilized accurately for the next 6 months. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of seven client records, the facility failed to include documentation of all the required client rights, including that the project may not discriminate in the provision of services on the basis of creed, sex, color, national origin, marital status, sexual orientation, handicap or religion in all seven records reviewed.Client # 1 was admitted on January 9, 2024 and was discharged on June 4, 2024. Client # 2 was admitted on April 8, 2024 and was discharged on June 27, 2024. Client # 3 was admitted on February 26, 2024 and was discharged on May 23, 2024. Client # 4 was admitted on January 25, 2024 and was discharged on May 9, 2024. Client # 5 was admitted on December 27, 2023 and was active at the time of the inspection. Client # 6 was admitted on March 12, 2024 and was active at the time of the inspection. Client # 7 was admitted on April 4, 2024 and was active at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations updated the EMR Document "Client's Rights and Responsibilities" on August 11, 2024, to reflect that the project may not discriminate in the provision of services on the basis of creed, sex, color, national origin, marital status, sexual orientation, handicap or religion in all seven records reviewed.
All current clients will sign the updated document by August 26, 2024, which will be reviewed by the Director of Clinical Operations. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of seven client records, the facility failed to include documentation of all the required client rights, including that the project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record, in all seven records reviewed. Client # 1 was admitted on January 9, 2024 and was discharged on June 4, 2024. Client # 2 was admitted on April 8, 2024 and was discharged on June 27, 2024. Client # 3 was admitted on February 26, 2024 and was discharged on May 23, 2024. Client # 4 was admitted on January 25, 2024 and was discharged on May 9, 2024. Client # 5 was admitted on December 27, 2023 and was active at the time of the inspection. Client # 6 was admitted on March 12, 2024 and was active at the time of the inspection. Client # 7 was admitted on April 4, 2024 and was active at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations updated the EMR Document "Client's Rights and Responsibilities" on August 11, 2024, to reflect that the project, facility, or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
All current clients will sign the updated document by August 26, 2024, which will be reviewed by the Director of Clinical Operations. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of seven client records, the facility failed to include documentation the required client rights, including that clients have the right to appeal a decision limiting access to their records to the director, in all seven records reviewed.Client # 1 was admitted on January 9, 2024 and was discharged on June 4, 2024. Client # 2 was admitted on April 8, 2024 and was discharged on June 27, 2024. Client # 3 was admitted on February 26, 2024 and was discharged on May 23, 2024. Client # 4 was admitted on January 25, 2024 and was discharged on May 9, 2024. Client # 5 was admitted on December 27, 2023 and was active at the time of the inspection. Client # 6 was admitted on March 12, 2024 and was active at the time of the inspection. Client # 7 was admitted on April 4, 2024 and was active at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations updated the EMR Document "Client's Rights and Responsibilities" on August 11, 2024, to reflect that clients have the right to appeal a decision limiting access to their records to the director.
All current clients will sign the updated document by August 26, 2024, which will be reviewed by the Director of Clinical Operations. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of seven client records, the facility failed to include documentation of the required client rights, including that clients have the right to submit rebuttal data or memoranda to their own records, in all seven records reviewed.Client # 1 was admitted on January 9, 2024 and was discharged on June 4, 2024. Client # 2 was admitted on April 8, 2024 and was discharged on June 27, 2024. Client # 3 was admitted on February 26, 2024 and was discharged on May 23, 2024. Client # 4 was admitted on January 25, 2024 and was discharged on May 9, 2024. Client # 5 was admitted on December 27, 2023 and was active at the time of the inspection. Client # 6 was admitted on March 12, 2024 and was active at the time of the inspection. Client # 7 was admitted on April 4, 2024 and was active at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations updated the EMR Document "Client's Rights and Responsibilities" on August 11, 2024, to reflect that clients have the right to submit rebuttal data or memoranda to their own records.
All current clients will sign the updated document by August 26, 2024, which will be reviewed by the Director of Clinical Operations. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of seven client records, the facility failed to document that the client was notified, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable record reviewed.Client # 2 was admitted on April 8, 2024 and was administratively discharged on June 27, 2024. The record contained no documentation that the client was notified, in writing, of the facility's decision to involuntarily terminate.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations updated the EMR Document "Discharge Follow-Up Call ? Synergy" on August 12, 2024, to reflect that clients who were involuntarily terminated were notified of the facility's decision in writing.
On August 12, 2024, the Director of Clinical Operations provided written documentation to Client #2 to notify the client of the facility's decision in writing.
The Director of Clinical Operations will ensure this newly revised form is utilized accurately by periodically checking for the next 6 months. |
709.92(a)(2) 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in six records reviewed.Client # 1 was admitted on January 9, 2024 and was discharged on June 4, 2024. The individual treatment and rehabilitation plan was completed on January 18, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client # 2 was admitted on April 8, 2024 and was discharged on June 27, 2024. The individual treatment and rehabilitation plan was completed on April 22, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client # 3 was admitted on February 26, 2024 and was discharged on May 23, 2024. The individual treatment and rehabilitation plan was completed on March 6, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client # 4 was admitted on January 25, 2024 and was discharged on May 9, 2024. The individual treatment and rehabilitation plan was completed on February 8, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client # 5 was admitted on December 27, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on January 10, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services.Client # 7 was admitted on April 4, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 16, 2024; however, the plan did not include documentation of the type and frequency of treatment and rehabilitation services. These finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations updated the EMR Document "Clinical Individualized Treatment Plan" on August 9, 2024, to offer checkbox options on the comprehensive treatment plan to state type and frequency of treatment as was stated on the initial treatment plan.
All current clients will have an attachment added under the treatment plan section to identify the type and frequency of treatment and rehabilitation services by August 26, 2024. This will be reviewed by the Director of Clinical Operations.
The Director of Clinical Operations will ensure this new addition is accurately filled out in charts for the next 6 months.
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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 ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in four of seven records reviewed.Client # 4 was admitted on January 25, 2024 and was discharged on May 9, 2024. The individual treatment and rehabilitation plan was completed on February 8, 2024, and the treatment plan update was due no later than April 8, 2024; however, the treatment plan update was not completed until April 15, 2024.Client # 5 was admitted on December 27, 2023 and was active at the time of the inspection. A treatment plan update was completed on March 8, 2024, and the next treatment plan update was due no later than May 8, 2024; however, the next treatment plan update was not completed until June 3, 2024. Client # 6 was admitted on March 12, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 21, 2024 and the treatment plan update was due no later than May 21, 2024; however, the treatment plan update was not completed until June 3, 2024. Client # 7 was admitted on April 4, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on April 16, 2024 and the treatment plan update was due no later than June 16, 2024; however, the treatment plan update was not completed until June 26, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Clinical Operations created an excel spreadsheet on August 6, 2024, to provide a tracking system for all clinical staff with documentation timelines. Treatment plan updates are listed in the document and this document is reviewed at the beginning of each supervision session.
In addition to this, to ensure this deficiency does not recur, the Director of Clinical Operations will conduct monthly chart audits to ensure compliance with the Department of Drug and Alcohol regulations and regular staff trainings will be conducted on treatment plan review process. |