INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 16, 2025 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from January, 2024 through December, 2024 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on May 15, 2025 and then not again until December 12, 2024.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/28/2025, documented training will be provided to the Facilities team responsible for conducting fire drills emphasizing the completion of drills during sleeping hours at least every 6 months. The VP of Facilities, in collaboration with the Quality Assurance Team, will conduct monthly audits of fire drill logs to ensure ongoing compliance with 705.10. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of inpatient client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in one out of one applicable client record.Client #6 was admitted on August 10, 2024 and was discharged on September 6, 2024. This finding was reviewed with facility staff during the licensing inspection
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Plan of Correction
By 02/28/2025, staff will be provided documented training related to the completion of Notice of Termination documentation and on the use of discharge checklists when processing a client's discharge. To ensure ongoing compliance with 709.33(a), a "Discharge Checklist" will be updated to include the requirement for Notice of Termination" when someone is involuntarily discharged from treatment. The BHT staff responsible for processing discharges will receive documented training regarding the use of the Discharge Checklist that includes the updated requirement for Notice of Termination when clients are involuntarily discharged from treatment. The discharge checklists will be maintained in the client record. The Quality Assurance team will conduct monthly chart reviews to monitor the effectiveness of corrective actions and, specifically, the completion of Termination Notifications. Additional individualized corrective actions will be implemented for staff that demonstrate failure to improve compliance with the above-mentioned standard. |
715.23(b)(4) LICENSURE Patient records
(b) Each patient file shall include the following information:
(4) The results of an initial intake physical examination.
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Observations
Based on the review of detox patient records, the facility failed to document a physical examination within the regulatory timeframe in one out of seven applicable records reviewed.Patient #8 was admitted on January 14, 2024 and was still active at the time of the inspection. No physical evaluation was completed.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/28/2025, documented training will be provided to the Medical team responsible for completing Physical Examinations with an emphasis on timeframes outlined in the organization's policies. To ensure ongoing compliance with organizational policies and regulatory standards, Quality Assurance tasks were created in the EHR system. This EHR system provides immediate notification to medical providers to complete a Health and Phsyical Examination. The QA Tasks provides deadlines and will send an alert to the Medical Provider team and will alert the Quality Assurance team when approaching the deadline. The Quality Assurance team will conduct monthly chart reviews to monitor timely completion of Physical Examinations. Additional individualized corrective actions will be implemented for staff that demonstrate failure to improve compliance with the above-mentioned standard. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of inpatient client records, the facility failed to document a physical examination according to the facility's policy and procedure in four out of seven records. The procedure states the physical examination will be completed within 72 hours.Client #1 was admitted on December 12, 2024 and was still active at the time of the inspection. The physical examination was completed on December 24, 2024.Client #3 was admitted on December 18, 2024 and was still active at the time of the inspection. The physical examination was completed on December 23, 2024.Client #4 was admitted on December 16, 2024 and was still active at the time of the inspection. The physical examination was completed on January 9, 2025.Client #7 was admitted on September 20, 2024 and was discharged on October 24, 2024. The physical examination was completed on September 24, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/28/2025, documented training will be provided to the Medical team responsible for completing Physical Examinations with an emphasis on timeframes outlined in the organization's policies. To ensure ongoing compliance with organizational policies and regulatory standards, Quality Assurance tasks were created in the EHR system. This EHR system provides immediate notification to medical providers to complete a Health and Phsyical Examination. The QA Tasks provides deadlines and will send an alert to the Medical Provider team of a required Physical Examination and its required completion date. During documented training, the medical providers will be educated on the use of these alerts and notifications to ensure timely completion of Physical Examinations. This newly created task system will alert the Quality Assurance team when Health and Physical Examinations are approaching the deadline. The Quality Assurance team will conduct monthly chart reviews to monitor timely completion of Physical Examinations and effectiveness of these corrective actions. Additional individualized corrective actions will be implemented for staff that demonstrate failure to improve compliance with the above-mentioned standard. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of inpatient client records, the facility failed to document a psychosocial evaluation according to the facility's policy and procedurs manuale in five out of seven records reviewed. The procedure states that the psychosocial evaluation will be completed within 72 hours. Client #2 was admitted on December 17, 2024 and was still active at the time of the inspection. The evaluation was not completed until December 23, 2024.Client #3 was admitted on December 18, 2024 and was still active at the time of the inspection. The evaluation was not completed until December 24, 2024.Client #5 was admitted on September 23, 2024 and was discharged on October 4, 2024. The evaluation was not completed until September 29, 2024. Client #6 was admitted on August 10, 2024 and was discharged on September 6, 2024. The evaluation was not completed until August 14, 2024.Client #7 was admitted on September 20, 2024 and was discharged on October 24, 2024. The evaluation was not completed until September 24, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/28/2025, documented training will be provided to the Counseling team responsible for completing Psychosocial Evaluations with an emphasis on timeframes outlined in the organization's policies. To ensure ongoing compliance with 709.51(b)(6), the a new QA Task alert system was created to notify counselors and Clinical Supervisors of Psychosocial Evaluations that are approaching deadlines for completion. The Clinical Supervisor will monitor daily reports of pending evaluations. Additionally, The Quality Assurance team will conduct monthly chart reviews to monitor effectiveness of our corrective actions and timely completion of Psychosocial Evaluations. Additional individualized corrective actions will be implemented for staff that demonstrate failure to improve compliance with the above-mentioned standard. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of inpatient client records, the facility failed to document a comprehensive treatment plan within the guidelines established by the facility's policy and procedures manual in six out of seven records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 72 hours following admission.Client #1 was admitted on December 12, 2024 and was still active at the time of the inspection.The comprehensive treatment plan was completed on December 23, 2024.Client #2 was admitted on December 17, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was completed on December 23, 2024.Client #3 was admitted on December 18, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was completed on December 24, 2024.Client #5 was admitted on September 23, 2024 and was discharged on October 4, 2024. The comprehensive treatment plan was completed on September 29, 2024. Client #6 was admitted on August 10, 2024 and was discharged on September 6, 2024. The comprehensive treatment plan was completed on August 16, 2024.Client #7 was admitted on September 20, 2024 and was discharged on October 24, 2024.The comprehensive treatment plan was completed on September 24, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/28/2025, documented training will be provided to the Counseling team responsible for completing Treatment Plans with an emphasis on timeframes outlined in the organization's policies. As part of this training, counselors will be educated about the newly created Task Notification/Alert system for Treatment Planning. To ensure ongoing compliance with 709.52(a), a QA Task Alert/Notification system was created in the organization's EHR system. This Alert system was created to provide an enduring alert/notification on the counselor's EHR homescreen notifying them of a treatment plan requiring completion and its corresponding deadline. This system will also notify the Clinical Supervisors of Treatment Plans approaching approaching the deadline. The Clinical Supervisor will monitor daily reports of pending treatment plans and coordinate with counseling staff to ensure timely completion. Additionally, The Quality Assurance team will conduct monthly chart reviews to monitor the effectiveness of our corrective actions and timely completion of Treatment Plans. Additional individualized corrective actions will be implemented for staff that demonstrate failure to improve compliance with the above-mentioned standard. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of inpatient client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in six out of six applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed every 15 days following admission.Client #1 was admitted on December 12, 2024 and was still active at the time of the inspection.Client #2 was admitted on December 17, 2024 and was still active at the time of the inspection. Client #3 was admitted on December 18, 2024 and was still active at the time of the inspection. Client #4 was admitted on December 16, 2024 and was still active at the time of the inspection.Client #6 was admitted on August 10, 2024 and was discharged on September 6, 2024. Client #7 was admitted on September 20, 2024 and was discharged on October 24, 2024.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
By 02/28/2025, documented training will be provided to the staff responsible for completing Case Consultations. This training will include education on the use of the newly created notification/alert system for tracking pending case consultations. To ensure ongoing compliance with 709.53(a)(8), a QA Task Alert/Notification system was created that will notify the counselor of a case consultation approaching its deadline on the staff's EHR homescreen. The alert system will also notify a Clinical Supervisors of any case consultations approaching its deadline. The Clinical Supervisor will monitor these alerts and coordinate with the treatment team to ensure timely completion of case consultations. Additionally, The Quality Assurance team will conduct monthly chart reviews to monitor the effectiveness of our corrective actions and timely completion of Case Consultations. Additional individualized corrective actions will be implemented for staff that demonstrate failure to improve compliance with the above-mentioned standard. |