INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Alcohol and Drug Abuse Services, 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in group counseling rooms #206 and #207.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In order to ensure privacy so that group counseling sessions cannot be seen or heard (based on 705.4 (3)). On 8/19/2022 cameras in Room 206 and 207 were disabled. These rooms will be a designated counseling group rooms and this will be identified on the doors. ADAS has a letter from Carlson Technologies indicating they are disabled. By 9/30/2022 the Cameras will be removed from the rooms by Carlson Technologies. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection, the facility failed to maintain two freezer temperatures according to the regulation. The facility's kitchen freezer temperature was measured at three degrees and ten degrees at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/10/22 the Inpatient supervisor met with the cook to review policy of checking freezer temperatures and verifying they are at 0 or below. The freezer is able to be locked at 0 degrees and was on this date. The cook will document weekly the temperature of the freezers. The inpatient supervisor will monitor weekly for compliance monthly. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a physical plant inspection, the facility failed to ensure that medication was being dispensed and documented on an individual basis, as the facility was dispensing client medication into individual initialed cups prior to medication times.
The finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 8/10/22 the Inpatient supervisor met with the Case Manager to address Maple Manor Medication Policy and the medications are made available at the designated times and may not be stored in anything but the original prescription bottles and that medication is dispensed and documented on an individual basis. The inpatient supervisor will observe the Case Manager during medication times 3 times a week and inspect the med room weekly to ensure compliance for the next 3 months. After this the med room will be inspected monthly and observations will occur if needed.
If at any time the Case Manager is not in compliance corrective measures will occur.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 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 four out of seven client records reviewed.
Client #1 was admitted on June 29, 2022 and was still active at the time of the inspection. A treatment plan was completed on July 1, 2022 and the next update was due no later than July 15, 2022; however it was not completed until July 27, 2022.
Client #2 was admitted on June 27, 2022 and was still active at the time of the inspection. A treatment plan was completed on June 29, 2022 and the next update was due no later than July 13, 2022; however it was not completed until July 26, 2022.
Client #3 was admitted on May 20, 2022 and was still active at the time of the inspection. A treatment plan was completed on May 24, 2022 and the next update was due no later than June 6, 2022; however it was not completed until June 17, 2022. The following treatment plan update was due on June 30, 2022; however it was not completed until July 15, 2022.
Client #5 was admitted on January 11, 2022 and discharged on February 24, 2022. A treatment plan was completed on January 24, 2022 and the next update was due no later than February 6, 2022; however it was not completed until February 22, 2022.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/9/22 the inpatient counselors were sent a memo by the Clinical Program Manager reinforcing the policy that updates be done every 14 days. On 8/17/22 the Inpatient counselors were retrained by the Clinical Program Manager on how to do updates and in the time frame as per policy.
The inpatient supervisor will review charts weekly to ensure updates are completed every 14 days. The Clinical Program Manager will review all discharge files monthly to ensure updates are being done every 14 days.
If at any time this is not being done it will be addressed with the individual counselor and corrective measures will occur.
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709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to verify that work done by the client was documented on treatment plans in three out of seven client records reviewed.
Client #1 was admitted on June 29, 2022 and was still active at the time of the inspection. A treatment plan was completed on July 1, 2022 with no work verification.
Client #2 was admitted on June 27, 2022 and was still active at the time of the inspection. A treatment plan was completed on June 29, 2022 with no work verification.
Client #7 was admitted on April 19, 2022 and was discharged on June 3, 2022. A treatment plan was completed on April 19, 2022 with no work verification.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
On 8/9/22 the Clinical Program Manager sent an email to the inpatient counselors reminding them that work therapy and chores is required on the treatment plan. On 8/17/22 the Clinical Program manager retrained the inpatient counselors on importance of adding work therapy and chores to the comprehensive treatment plan and continue this goal on all subsequent treatment plan updates.
The Clinical Supervisor will review files weekly to ensure compliance and the Clinical Program Manager will review monthly for compliance. If at any time this is not occurring corrective action with the counselor will occur.
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