INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 23 - 25, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Deerfield Center for Addictions 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 (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 fire drill logs, the facility failed to document unannounced fire drills at least once a month.
The fire drill logs were reviewed for the time period of April 2021 - March 2022. There was no fire drill documented for the month of May 2021.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the April 14, 2021 annual licensing inspection.
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Plan of Correction
Regarding 705.28 Fire Safety Regulation and Deerfield's failure to comply with a mandatory monthly fire drill and documentation for non-residential facilities- The Clinical Director of Drug and Alcohol Treatment Programming will, starting in April of 2022, be responsible for the rotating monthly fire drill within all Deerfield outpatient programming. The Clinical Director will perform fire drills on a monthly rotation of AM and PM times, rotation of front exit and back exit departure and count of building occupants, and documentation into fire safety binder by location, date, and time of the drill.
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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 document a 30-day follow up, based on agency policy, in one of one client records.
Client #3 was admitted on July 8, 2021 and discharged on February 8, 2022. A 30-day follow up was due to be completed by March 8, 2022. There was no follow up documented in client record #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Regarding 709.93 Client record deficiencies related to a failed 30 day follow up on client #3 from Tionesta location- License 627027-The clinical director provided direct in-person training to all support and clinical staff on 4/1/2022 regarding the procedure for completion of the 30 day follows up of all discharged clients. The assigned clinician of any discharged client will prepare the necessary client aftercare follow-up survey to be mailed directly to the client when completing the discharge summary. The prepared follow-up survey will be scanned into an individual client chart, placed in a file system maintained by support staff for outgoing mail sorted by mail date, and logged into the aftercare follow-up binder. Clinical Director will monitor monthly discharges to assure that the discharge survey is logged into the chart and file binder. Support Staff will scan all returned follow-up surveys into the client chart and file them in an aftercare binder. |