INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 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, Ascend Clinical Services 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 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from February 2023 - December 2023, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of April and October 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A documented training will be provided to relevant leadership staff, including the facility's Operations Manager, by 02/23/2024. The training will address the need to conduct monthly documented fire drills.
To ensure compliance with 705.28(d)(1), the Compliance Officer will conduct quarterly review of the Fire Drill logs to ensure Fire Drill are being conducted in accordance with internal policy and regulatory standards. |
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.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in one out of three applicable records reviewed.
Client #5 was admitted on October 13, 2023 and was discharged on January 17, 2024
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 02/13/2024, documented discharge summaries will be documented for client 5.
Documented training will be provided to clinical staff by 02/23/2024 regarding the need to maintain complete client records that include discharge summaries.
To ensure ongoing compliance with 709.93(a)(11), the Compliance Officer will conduct monthly chart reviews to monitor compliance with internal policies and regulatory standards related to completion of discharge summaries. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow up information in one out of three applicable records reviewed.
Client #5 was admitted on October 13, 2023 and was discharged on January 17, 2024
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 02/13/2024, documented follow-up calls will be completed for Client 5
Documented training will be provided to clinical staff by 02/23/2024 regarding the need to maintain complete client records that include follow up information.
To ensure ongoing compliance with 709.93(a)(11), the Compliance Officer will conduct monthly chart reviews to monitor compliance with internal policies and regulatory standards related to documentation of follow-up information. |