D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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TREATMENT TRENDS INC.
18-22 SOUTH SIXTH STREET, PO BOX 685
ALLENTOWN, PA 18101

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Survey conducted on 01/16/2020

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on January 15, 2020 through January 16, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, Treatment Trends Inc, Keenan House, 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
705.10 (d) (1) LICENSURE Fire safety. 705.10. Fire safety. (d) Fire drills. The residential facility shall: (1) Conduct unannounced fire drills at least once a month.
Observations During the review of facility fire drill logs on January 16, 2020, the facility failed to document unannounced monthly fire drills. There was no documentation for the month of March 2019 that an unannounced fire drill was conducted. These findings were reviewed with facility staff during the licensing process.	Plan of Correction In response to standard violation 705.10(d)(1), Fire safety, the Supervisor of Support Staff will review the existing Fire Drill schedule and discuss shift staff responsible to ensure the drill is planned. The Supervisor of Support Staff will then check the Fire Drill Log by the 20th of each month to ensure the drill was carried out as scheduled. This process will begin as of February 3, 2020.
709.34 (b) (5) LICENSURE Reporting of unusual incidents § 709.34. Reporting of unusual incidents. (b) Policies and procedures must include the following: (5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
Observations During a review of unusual incident reports on January 16, 2020, the facility failed to implement and utilize a proper reporting mechanism to ensure that reporting of an unusual incidents to an entity is in compliance with State and Federal confidentiality laws. The facility failed to utilize a proper reporting mechanism for twenty-one applicable incidents that were not reported within State and Federal confidentiality laws. These findings were reviewed with facility staff during the licensing process.	Plan of Correction With change of staffing, the system of reporting unusual incident compliance failed to occur in 21 incidents during 2019. This violation has been remedied. The Clinical Director will work directly with the Utilization Review staffer when any unusual incident occurs to ensure the proper paperwork is completed and the State and Federal confidentiality laws are observed. Two such incidents have been properly reported so far. This corrective action began on January 22, 2020.
709.34 (c) (4) LICENSURE Reporting of unusual incidents § 709.34. Reporting of unusual incidents. (c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving: (4) Event at the facility requiring the presence of police, fire or ambulance personnel.
Observations The facility failed to notify the department within three business days of an event at the facility requiring the presence of police, fire, or ambulance personnel on twenty-one separate occasions. The following were dates in which incident reports were not submitted to the facility. On January 3, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On January 12, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On January 21, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On February 23, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On March 11, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On March 13, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On April 12, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On April 15, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On April 16, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On May 29, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On June 10, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On June 21, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On June 28, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On July 2, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On July 14, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On July 15, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On July 19, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On July 20, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On July 25, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On August 12, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. On September 1, 2019, an event occurred at the facility required that required the presence of police, fire, or ambulance personnel. These findings were reviewed with facility staff during the licensing process.	Plan of Correction To ensure notification occurs within three business days of an event requiring police, fire or ambulance personnel, as noted in standard 709.34(c)(4), the information gathered by the Clinical Director will be passed on to the Utilization Review manager who will complete all the necessary paperwork for submission to DDALP. The Clinical Director will log the occurrence with a copy of the paperwork. This log will be inspected monthly by the Program Director to ensure the system is functioning properly. This system began January 22, 2020.