INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 18, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Public Health Management Corporation d/b/a Chances 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) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's November 2022 through August 2023 fire drill logs, the facility failed to ensure that unannounced fire drills were conducted at least once a month. There were no fire drills conducted during each of the months of April 2023 through August 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that unannounced Fire drills are conducted at least once per month. The Program Director or the Program Director's assigned designee will conduct the unannounced fire drill and document the results of the unannounced fire drill in the agency fire drill log. The Program Director will review the fire drill logs at least monthly to ensure that the drills were conducted and that the documentation of the drills are complete according to the 705.28 (d) (1). The Program Director will review this plan of correction with all staff responsible for conducting and documenting fire drills at the PHMC CHANCES facility by 11/15/2023. |
709.34 (c) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day.
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Observations
Based on a review of the facility's November 2022 through August 2023 unusual incident logs and a conversation with facility staff, the facility failed to file a written unusual incident report with the Department within 3 business days following a significant disruption of services due to a disaster such as fire, storm, flood, or other occurrence that results in the closure of the facility for more than 1 day.
The facility discharged all active clients and ceased operations as of March 31, 2023. There was no unusual incident report regarding the facility closure filed with the Department as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director will ensure that incidents are filed with the Department within 3 business days following an unusual incident involving Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence that results in the closure of a facility for more than 1 day according to regulation code 709.34 (c) (3).
The Program Director or the Program Director's assigned designee will file an incident report with the Department within 3 business days following an unusual incident involving Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
The Program Director will review incident reports filed with the Department each time they are submitted, to ensure that they are submitted according to regulation code 709.34 (c) (3).
The Program Director will review this plan of correction with all staff responsible for reporting and documenting incident reports for the PHMC CHANCES facility by 11/15/2023.
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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 two applicable client records reviewed.
Client # 6 was admitted on November 11, 2022 and was discharged on February 8, 2023. The individual treatment plan was completed on November 23, 2022 and an update was due no later than January 23, 2023; however, the update was not completed prior to discharge.
Client # 7 was admitted on November 11, 2022 and was discharged on March 29, 2023. The individual treatment plan was completed on December 6, 2022 and an update was due no later than February 6, 2023; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All program staff and supervisors who are responsible for the development and documentation of treatment plans will be trained by the Program Director and/or Clinical Supervisor on the 709.92(b) Treatment and rehabilitation services requirement, including that an individual treatment and rehabilitation plan shall be reviewed and updated at least every 60 days.
The Program Director and/or Clinical Supervisor will maintain a list of client treatment and rehabilitation plan due dates and completion dates. This list will be reviewed at every therapist individual staff supervision meeting and at every clinical team meeting.
During regular (e.g. biannual) client file reviews, The PHMC Compliance Department will monitor that individual treatment and rehabilitation plans were reviewed and updated at least every 60 days, and that documentation was filed in the client record. The Compliance Department will report any findings to the Program Director for internal Plans of Correction.
All program staff and supervisors who are responsible to review and update treatment plans will be trained by the Program Director and/or Clinical Supervisor on this plan of correction by 11/15/2023.
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709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record, which is to include documentation of follow-up information, in six of seven client records reviewed.
Client # 2 was admitted on December 20, 2022 and was discharged on February 13, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Client # 3 was admitted on December 8, 2022 and was discharged on January 27, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Client # 4 was admitted on November 30, 2023 and was discharged on February 6, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Client # 5 was admitted on November 29, 2022 and was discharged on February 7, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Client # 6 was admitted on November 11, 2022 and was discharged on February 8, 2023. There was no follow-up information documented in the record as of the date of the inspection.
Client # 7 was admitted on November 11, 2022 and was discharged on March 29, 2023. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff and supervisors who are responsible for Follow-up information will be trained by the Program Director and/or by the Clinical Supervisor on the 709.93(a)(11) Follow-up information requirement, including that There shall be a complete client record on an individual which includes information relative to the client's involvement with the project; this shall include, but not be limited to, Follow-up information.
The Program Director and/or Clinical Supervisor will maintain a list of all client discharges, and will review on a weekly and monthly basis that follow up is occurring and documented in client records post-discharge. The Program Director and/or the Clinical Supervisor will use reports from the agency Electronic Health Record to ensure that follow up is occurring and documented in client records post-discharge. Follow-up documentation will be reviewed at every therapist individual staff supervision meeting for every client assigned to the clinician, and at every clinical team meeting for all discharged clients. Documentation of compliance with the 709.93(a)(11) Follow-up information requirement will be made in the staff member's individual supervision notes and/or in clinical team meeting notes.
During regular (e.g. biannual) client file reviews, The PHMC Compliance Department will monitor that follow up information documentation is present in the official client record. The Compliance Department will report any findings to the Program Director for internal Plan of Correction.
All staff and supervisors who are responsible for Follow-up information will be trained on this plan of corrective by the Program Director and/or by the Clinical Supervisor by 11/15/2023.
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