INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 2, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Central Behavioral Health 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:
|
Plan of Correction
|
705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
|
Observations
Based on a physical plant inspection on August 2, 2024, the facility failed to ensure that garbage was stored in covered containers that prevent the penetration of insects and rodents as there was an uncovered dumpster in the rear parking lot of the building.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Following the inspection on 8/2/2024, the facility director reached out to the facilities/grounds staff about the missing dumpster lid. On 8/5/2024 the facility director was informed that Mascaro, the company that owns and operates the dumpsters, was made aware that a replacement lid was needed. The facility director will follow up with the company if a lid is not replaced by 8/25/2024.
The facility director will inspect the dumpster's lids monthly during fire drills and grounds inspections to confirm that they remain in compliance. |
705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
|
Observations
Based on a physical plant inspection on August 2, 2024, the facility failed to ensure privacy so that counseling sessions cannot be seen outside the counseling room. Office # 105 could be seen outside of the room through an exterior window with no window covering.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/5/2024 the facility director reached out to facilities/grounds staff about getting appropriate window dressings installed in office room 105. Ground staff said they will install adjustable blinds within the next week. As of 8/2/2024, the facility director informed all building staff that room 105 is not to be used for therapy/counseling services until the window treatment is installed.
Going forward, the facility director will inspect the presence and function of window dressings in all offices in the building where clinical services are provided. This will occur as needed, but also be a part of the monthly fire drill/grounds inspection process. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of one client record, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in one record reviewed.
Client # 2 was admitted on February 5, 2024 and was active at the time of the inspection. The treatment plan completed on May 21, 2024, indicated that the client was to receive one individual session per week; however, there was no documentation of individual sessions the weeks of June 17, 2024 or June 24, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/2/2024, immediately following the inspection of the program, the facility director met with the counselor who provides treatment to client #2. The importance of documenting any gaps in treatment was reviewed, including how to document when the counselor is away on vacation and when the client reaches out well in advance to cancel the appointment.
The facility director will monitor that any gaps in treatment are documented in client charts by reviewing charts together in weekly supervision meetings with the counselor. If any gaps in the future are identified and had not been documented, the facility director will have the counselor document them afterwards to ensure an explanation for the gap in treatment is explained. |
709.93(a)(10) 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:
(10) Discharge summary.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include a discharge summary in one of one applicable records reviewed.
Client # 1 was admitted on March 25, 2024 and was discharged on May 22, 2024. There was no documentation of a discharge summary in the record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 8/2/2024, immediately following the inspection of the program, the facility director met with the counselor who provides treatment to client #1. It was identified that even though the client was assigned to the counselor, they had not actually met and there was some confusion as to who completes the discharge summary in those instances.
The following was added to the program's policy and procedures manual on 8/7/2024: "In instances where a client is discharged from the program and there were no completed services aside from the initial evaluation, it will fall upon the facility director to complete the discharge summary."
Going forward, the facility director will review all discharges in the program and assign discharge summary duties based on the above stated policy. |