INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 29, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, PA Treatment and Healing 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 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment. Staff #3 was hired on May 20, 2024, as a counselor and was still in this position as of the date of the inspection. The training was completed on June 7, 2024.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff have been made aware that all new hires must be trained in fire safety within the first 7 days of employment. This is to include the use of fire extinguishers. This training is then to be reviewed annually. This timeline has been added to the new hire training packet. The supervisor on site will be responsible for having the new hire complete the training within the allotted time frame. This will then be monitored for compliance by the HR Director and the Project Director within 10 days of hire. |
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 the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies. Staff #3 was hired on May 20, 2024, as a counselor and was still in this position as of the date of the inspection. The training was completed on June 7, 2024. These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff have been made aware that all new hires must be trained in fire safety within the first 7 days of employment. This is to include all designated assigned tasks during an emergency. This training is then to be reviewed annually. This timeline has been added to the new hire training packet. The supervisor on site will be responsible for having the new hire complete the training within the allotted time frame. This will then be monitored for compliance by the HR Director and the Project Director within 10 days of hire. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from July 2023 - August 2024, the facility failed to prepare alternative exit route to be used during fire drills, as all fourteen drills utilized the same exit routes. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been retrained in the procedure for carrying out fire drills, including the need to utilize different exits throughout the facility during the drills. The Project Director will monitor the completed drills, monthly, to ensure that different exits are being utilized. If the same exit is utilized more than 2 drills consecutively, then an additional drill will be completed for the month. Should a pattern of repeated exits be consistently found, then staff will be offered retraining. |
709.28 (c) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document a completed consent to release information form which included specific information to be disclosed in two out of seven records reviewed. Client #4 was admitted on November 10, 2023, and was discharged on August 14, 2024. A release of information form signed and dated November 10, 2023 was to the local Single County Authority. Client #5 was admitted on November 17, 2023, and was discharged on April 15, 2024. A release of information form signed and dated February 5, 2024 was to the local Single County Authority. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been retrained in the completion of consents, including the designation of specific information to be disclosed. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician, for each level of care. If a consent is found to be invalid, the clinician will be given 7 days to contact the client and correct. The chart will then be re-reviewed within 10 days. If the consent remains invalid, the staff will be supplied with a 1-1 refresher training. If this event occurs 3 or more times, disciplinary action will be taken. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the dated signature of the client in one out of seven applicable records reviewed.Client # 2 was admitted on February 13, 2024, and was still active at that the time of the inspection. A release of information dated by the witness on February 13, 2024, for the SCA did not include a client signature. Additionally, a release of information form dated by the witness on May 10, 2024, for probation did not include a client signature. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff have been retrained in the completion of consents, including the dated signature of both the clinician and the client. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician, for each level of care. If a consent is found to be invalid, the clinician will be given 7 days to contact the client and correct. The chart will then be re-reviewed within 10 days. If the consent remains invalid, the staff will be supplied with a 1-1 refresher training. If this event occurs 3 or more times, disciplinary action will be taken. This specific deficiency has been addressed with new releases completed by the client in question on 9/10/24. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of the client records, the facility failed to document that a copy of a client consent was offered to the client in one out of seven client records reviewed. Client #5 was admitted on November 17, 2023, and discharged on April 15, 2024. A release of information form signed and dated November 17, 2023, was to probation.This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All staff have been retrained in the completion of consents, including whether or not the client accepted or declined a copy of the consent. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician, for each level of care. If a consent is found to be invalid, the clinician will be given 7 days to contact the client and correct. The chart will then be re-reviewed within 10 days. If the consent remains invalid, the staff will be supplied with a 1-1 refresher training. If this event occurs 3 or more times, disciplinary action will be taken. |
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 document treatment plan updates within the regulatory timeframe in five out of seven applicable client records. Client #1 was admitted on April 3, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was completed on April 17, 2024, and an update was due no later than June 17, 2024; however, the next update was completed on June 19, 2024. Additionally, the next treatment plan update was due no later than August 19, 2024; however, there was no update documented in the client record at the time of the inspection. Client #3 was admitted on January 2, 2024, and was still active at the time of the inspection. A treatment plan update was completed on June 3, 2024, and the update was due no later than August 3, 2024; however, the next update was completed on August 6, 2024. Client #4 was admitted on November 10, 2023, was discharged on August 14, 2024. A treatment plan update was completed on January 11, 2024, and the update was due no later than March 11, 2024; however, the next update was completed on March 14, 2024. Additionally, the next treatment plan update was due no later than May 14, 2024; however, there was no update documented in the client record at the time of the inspection. Client #5 was admitted on November 17, 2023, was discharged on April 15, 2024. A treatment plan update was completed on December 18, 2023, and the update was due no later than February 18, 2024; however, the next update was completed on February 26, 2024. Client #6 was admitted on September 28, 2023, was discharged on March 1, 2024. A comprehensive treatment plan was completed on October 19, 2023, and the update was due no later than December 19, 2023; however, the next update was completed on January 10, 2024. This is a repeat citation from the October 6, 2021, August 11, 2022 and August 9, 2023 licensing inspections. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been retrained in the completion of treatment plan updates, including the timelines for when they are to be completed. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician, for each level of care. If a treatment plan update is found to not have been completed within the designated time frame, the clinician will be given 7 days to document in a progress note, why the plan was not completed in a timely manner. The chart will then be re-reviewed within 10 days. If treatment plan updates continue to be late, the staff will be supplied with a 1-1 refresher training. If this event occurs 3 or more times, disciplinary action will be taken. For client #2, a treatment plan update will be completed at the next appt, which is on 9/11/24. |
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.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plans in three out of seven applicable records reviewed.Client #1 was admitted on April 3, 2024, and was still active at the time of the inspection. The updated treatment plan dated June 19, 2024, indicated the client would receive one individual therapy session per week During the month of July 2024 only one individual session was documented in the client record. Client #4 was admitted on November 10, 2023, and was discharged on August 14, 2024. The updated treatment plan dated March 14, 2024, indicated the client would receive one individual session per week. During the month of July 2024 only one individual session was documented in the client record. Client #7 was admitted on December 14, 2024, and discharged on August 7, 2024. The comprehensive treatment plan dated December 26, 2023, indicated the client would receive one individual session per week. During the month of July 2024 only one individual session was documented in the client record.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been retrained in the completion of treatment plan reviews, including the need for them to reflect how many group and individual services that a client is to attend per week or month. When the number of services suggested changes, then the treatment plan update needs to reflect that change. Additionally, progress notes will be written for any missed service and filed in the client chart. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician, for each level of care. If treatment plan update is found to not be reflective of changes or missed service notes are not filed, the clinician will have 7 days to correct the issue. The chart will then be re-reviewed within 10 days. If the treatment plan remains Un updated or notes missing, the staff will be supplied with a 1-1 refresher training. If this event occurs 3 or more times, disciplinary action will be taken. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on the review of client records, the facility failed to comply with plans of correction approved by the Department.A plan of correction for treatment plan updates were submitted and approved by the Department for the October 6, 2021, August 11, 2022 and August 9, 2023 annual licensing inspections. Tretment plan updates were again found to be a deficiency in the August 29, 2024 licensing inspection. . This is a repeat ciation form the August 9, 2023 licesing renewal inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff have been retrained in the completion of treatment plan reviews, including the need for them to reflect how many group and individual services that a client is to attend per week or month and to be completed within the timeframes outlined in the policy and procedure manual. When the number of services suggested changes, then the treatment plan update needs to reflect that change. Additionally, progress notes will be written for any missed service or when a treatment plan update was completed outside of the allotted parameters and filed in the client chart. This will be monitored by monthly chart audits, conducted by the site supervisor, consisting of 3 randomly selected charts from each clinician, for each level of care. If treatment plan update is found to not be reflective of changes or missed service notes are not filed, the clinician will have 7 days to correct the issue. The chart will then be re-reviewed within 10 days. If the treatment plan remains Un updated or notes missing, the staff will be supplied with a 1-1 refresher training. If this event occurs 3 or more times, disciplinary action will be taken. |