INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10, 2023 through April 11, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Holcomb Associates Inc., 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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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on the review of the facility's policy and procedure manual on April 10, 2023, the facility failed to include, in their unusual incident policy, written procedures to follow regarding a physical assault or sexual assault by staff or a client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a policy which documents general procedures for unusual incidents. The policy failed to include specifically physical assault or sexual assault by staff or client and procedures to follow when these incidents occur. As a correction, the facility is updated the policy and procedures to include steps that will be taken when physical assault or sexual assault by staff or a client, such as:
a.Staff or client removed to a safe place and clinical support offered.
b.Emergency personnel is notified and medical attention is provided as necessary.
c.Incident Report is completed and Incident Management Committee and Human Resources are notified within 24 hours. Investigation by Incident Management Committee is completed.
d.All notification to licensing bodies made as applicable.
The Clinical Coordinator and Clinical Manager provided training to all staff on updated policies. Staff reviewed and signed off on policy and procedure updates.
The updated policy and procedures are accessible to all program staff for reference and use as needed.
Further, the Project Director and Quality Management Committee will continue to monitor monthly to ensure compliance with unusual incident reporting.
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709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on the review of the facility's policy and procedure manual on April 10, 2023, the facility failed to develop, in their unusual incident policy, a policy and written procedures to follow regarding the selling or use of illicit drugs on the premises.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a policy which documents general procedures for unusual incidents. The policy failed to include specifically selling or use of illicit drugs on the premises and procedures to follow when these incidents occur. As a correction, the facility is updated policy and procedures to include steps that will be taken when selling or use of illicit drugs on the premises, such as: a.Drugs found on property are disposed following hazardous disposal protocol.
b.Emergency personnel is notified
c.If a staff is involved in selling illicit drugs on premises, Human Resources is notified and an investigation takes place.
d.If a client is involved the program will reassess appropriate level of care following ASAM protocol.
e.Incident report is completed within 24 hours and provided to Incident Management Committee. The committee will determine if further investigation is warranted. The Clinical Coordinator and Clinical Manager will provided a training to all staff on updated policies. Staff reviewed and signed off on policy and procedure updates.
The updated policy and procedures are accessible to all program staff for reference and use as needed.
Further, the Project Director and Quality Management Committee will continue to monitor monthly to ensure compliance with unusual incident reporting. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on the review of the facility's policy and procedure manual on April 10, 2023, the facility failed to include, in their unusual incident policy, a policy and written procedures to follow regarding a death or serious injury due to trauma. Suicide, medication error, or unusual circumstances.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a policy which documents general procedures for unusual incidents. The policy failed to include specifically a death or serious injury due to trauma, suicide, medication error, or unusual circumstances and procedures to follow when these incidents occur. As a correction, the facility is updated policy and procedures to include steps that will be taken when a death or serious injury due to trauma, suicide, medication error, or unusual circumstances, such as: a. Emergency personnel is notified as applicable. When applicable, physical safety is established and clinical support offered.
b. Notify emergency contacts.
c.Consult with Medical Director and Clinical Director as appropriate
d.Incident Report is completed and Incident Management Committee and Human Resources are notified within 24 hours. Investigation by Incident Management Committee is completed as necessary.
e.All notification to licensing bodies made
f.Morbidity and Mortality review is completed when a death occurs The Clinical Coordinator and Clinical Manager provided a training to all staff on updated policies. Staff reviewed and signed off on policy and procedure updates.
The updated policy and procedures are accessible to all program staff for reference and use as needed.
Further, the Project Director and Quality Management Committee will continue to monitor monthly to ensure compliance with unusual incident reporting.
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709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on the review of the facility's policy and procedure manual on April 10, 2023, the facility failed to include, in their unusual incident policy, written procedures to follow regarding a theft, burglary, break-in, or similar incident at the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a policy which documents general procedures for unusual incidents. The policy failed to include specifically theft, burglary, break-in or similar incident at the facility, and procedures to follow when these incidents occur. As a correction, the facility is updated policy and procedures to include steps that will be taken when theft, burglary, break-in or similar incident at the facility, such as: a. Emergency personnel is notified as applicable. When applicable, physical safety is established and clinical support offered.
b.Incident Report is completed and Incident Management Committee and Human Resources are notified within 24 hours. Investigation by Incident Management Committee is completed as necessary.
c.All notification to licensing bodies made
d.Follow Chapter 24 for Emergency plan. The Clinical Coordinator and Clinical Manager provided a training to all staff on updated policies. Staff reviewed and signed off on policy and procedure updates.
The updated policy and procedures are accessible to all program staff for reference and use as needed.
Further, the Project Director and Quality Management Committee will continue to monitor monthly to ensure compliance with unusual incident reporting. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on the review of the facility's policy and procedure manual on April 10, 2023, the facility failed to include, in their unusual incident policy, written procedures to follow regarding structural damage to the facility.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a policy which documents general procedures for unusual incidents, including structural damage to the facility. The policy failed to specifically outline procedures to follow when these incidents occur. As a correction, the facility updated policy and procedures to include steps that will be taken when there is structural damage to the facility, such as: a.Emergency personnel is notified as applicable. When applicable, physical safety is established and clinical support offered.
b.Incident Report is completed and Incident Management Committee and Human Resources are notified within 24 hours. Investigation by Incident Management Committee is completed as necessary.
c.All notification to licensing bodies made
d.Follow Chapter 24 for Emergency plan. The Clinical Coordinator and Clinical Manager provided a training to all staff on updated policies. Staff reviewed and signed off on policy and procedure updates.
The updated policy and procedures are accessible to all program staff for reference and use as needed.
Further, the Project Director and Quality Management Committee will continue to monitor monthly to ensure compliance with unusual incident reporting.
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709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on the review of the facility's policy and procedure manual on April 10, 2023, the facility failed to include, in their unusual incident policy, written procedures to follow regarding the outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a policy which documents general procedures for unusual incidents. The policy failed to include specifically outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification, and procedures to follow when these incidents occur. As a correction, the facility is updated policy and procedures to include steps that will be taken when outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification, such as: a. Notify CDC and other licensing bodies.
b. Incident Report is completed and Incident Management Committee and Human Resources are notified within 24 hours. Investigation by Incident Management Committee is completed as necessary.
c. Notify emergency and medical personnel as appropriate. Notify emergency contact as appropriate.
d. Implementing health and safety protocol detailed in Infection Control policy and procedure The Clinical Coordinator and Clinical Manager provided a training to all staff on updated policies. Staff reviewed and signed off on updated policies and procedures.
The updated policy and procedures are accessible to all program staff for reference and use as needed.
Further, the Project Director and Quality Management Committee will continue to monitor monthly to ensure compliance with unusual incident reporting.
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709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on the review of the facility's policy and procedure manual on April 10, 2023, the facility failed to include, in their unusual incident policy, written procedures to follow regarding the implementation of a timely and appropriate corrective action plan, when indicated.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a policy which documents general procedures for unusual incidents. The policy failed to include specifically implementation of a timely and appropriate corrective action plan when indicated, and procedures to follow when these incidents occur. As a correction, the facility is updated policy and procedures to include steps that will be taken when implementation of a timely and appropriate corrective action plan occur, such as: 1.Incident Management, Compliance, and Human Resources are notified with the completion of an incident report within 24 hours.
2.An investigation, administrative review and corrective plan is completed by Compliance if necessary depending upon the severity of the incident. It is the responsibility of the Facility Director to ensure Corrective Plan is implemented. The Clinical Coordinator and Clinical Manager provided a training to all staff on updated policies. Staff reviewed and signed off on updated policies and procedures.
The updated policy and procedures are accessible to all program staff for reference and use as needed.
Further, the Project Director and Quality Management Committee will continue to monitor monthly to ensure compliance with unusual incident reporting.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on the review of the facility's policy and procedure manual on April 10, 2023, the facility failed to include, in their unusual incident policy, written procedures to follow regarding the ongoing monitoring of the corrective action plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility does have a policy which documents general procedures for unusual incidents, including ongoing monitoring of a corrective action plan. The policy failed to specifically outline procedures to follow when these incidents occur. As a correction, the facility updated policy and procedures to include steps that will be taken for ongoing monitoring of a corrective action plan, such as: 1.The corrective action plan will dictate the responsible party of monitoring the completion of the plan.
2.The responsible party will notify the Facility Director and Compliance upon completion of the plan.
3.The Incident Management Committee will then approve completion.
The Clinical Coordinator and Clinical Manager provided a training to all staff on updated policies. Staff reviewed and signed off on updated policies and procedures.
The updated policy and procedures are accessible to all program staff for reference and use as needed.
Further, the Project Director and Quality Management Committee will continue to monitor monthly any/all current corrective action plans to ensure compliance with unusual incident reporting.
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