INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Persad Center, 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of applicable staff records, the facility failed to provide a mechanism to provide feedback on a completed training in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicated that staff are to complete feedback forms for each training once completed in two of two records. Staff #1 was hired as a counselor on April 12, 2021 and promoted to project/facility director on June 1, 2023. The facility was unable to provide feedback collected from trainings for Staff #1.Staff #2 was hired as a counselor on July 18, 2018 and has been working in the facility ' s drug and alcohol treatment program since November 1, 2021. The facility was unable to provide feedback collected from trainings for Staff #2.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Project Director will develop a Training Evaluation form to be completed after every training. Staff will be asked to complete and return the form to the Project Director within 7 days from the completion of the training. The Project Director will update the policy in the Program Manual and review the updates with all staff.
The Project Director will monitor the completion of the training evaluations at the end of each month. |
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 the facility fire drill log for the months of April 2022 through June 2023, the facility failed to prepare alternate exit routes to be used during fire drills.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Project Manager will meet with the Facility and Operations Coordinator to review the requirements for regular fire drills. Facility and Operations Director will identify alternative exit routes to be used during future fire drills.
The Project Manager will review the fire drill logs quarterly to ensure compliance. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility fire drill log for the months of April 2022 through June 2023, the facility failed to conduct fire drills at different times of the day. Fire drills were conducted between 8:30am and 9:57am in fourteen of fifteen logs.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Project Manager will meet with the Facility and Operations Coordinator to review the requirements for regular fire drills. Going forward, the Facility and Operations Director will conduct fire drills at different times of the day and record those times in the Fire Drill Log.
The Project Manager will review the fire drill logs quarterly to ensure compliance. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of the facility annual report, the facility failed to make an annual report available to the public. During the inspection, the facility provided the most recent annual report which was completed for the 2019-2020 fiscal year.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the requirement for the annual report with the Executive Director and Clinical Director. The Executive Director's Administrative Team is in the process of completing the annual report for the 2022-2023 fiscal year.
The Project Manager will review and remind the Executive Director and Administrative Staff of the need for completion of the annual report at the end of the second quarter.
The Project Manager will review the annual report when it is completed annually. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on applicable staff records reviewed, the facility failed to provide documentation of an annual written individual staff performance evaluations reviewed and signed by the employee in one of three records. Staff #2 was hired as a counselor on July 18, 2018 and has been working in the facility ' s drug and alcohol treatment program since November 1, 2021. An annual performance evaluation has not been completed since the transition to the drug and alcohol program.This is a repeat citation from the August 16, 2022 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director reviewed the policy for annual performance evaluations with the Clinical Director. The Clinical Director will complete a performance evaluation for Staff #2 by October 31, 2023.
The Facility Director has made a spreadsheet to track the completion of annual performance evaluations for all Drug and Alcohol Program staff. |
709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on applicable client records reviewed, the facility failed to provide a preliminary treatment plan in accordance with the facility policy and procedure manual in five out of six applicable records. The facility policy and procedure manual indicated a preliminary treatment plan be completed during the intake process.Client #1 was admitted on February 7, 2023 and discharged on April 6, 2023. The preliminary treatment plan was to be completed on February 7, 2023, but was not completed until February 17, 2023. Client #3 was admitted on September 22, 2022 and still active at the time of the inspection. The preliminary treatment plan was to be completed on September 22, 2022, but was not completed until October 6, 2022.Client #5 was admitted on October 25, 2022 and still active at the time of the inspection. The preliminary treatment plan was to be completed on October 25, 2022, but was not completed until November 1, 2022.Client #6 was admitted on April 1, 2023 and still active at the time of the inspection. The preliminary treatment plan was to be completed on April 1, 2023, but was not completed until April 6, 2023.Client #7 was admitted on June 23, 2023 and still active at the time of the inspection. The preliminary treatment plan was to be completed on June 23, 2023, but was not completed until July 13, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Manager has changed the due date for the initial treatment plan. Initial treatment plans will be done at the first session following intake. The Facility Manager will amend the policy and update the Procedure Manual.
Project Manager will then review new policy with Drug and Alcohol team.
The Facility Director will schedule quarterly peer reviews of client files to ensure compliance to the plans of correction.
Results of the peer reviews will be discussed quarterly in Drug and Alcohol Team Meetings.
Any lapses in compliance will be addressed via a coaching session with Drug and Alcohol staff. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on applicable client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in five of five records. The facility policy and procedure manual indicate a case consultation to occur every sixty days. Client #2 was admitted on November 8, 2021 and discharged on May 8, 2023. No case consultations were documented since the last licensing inspection on August 16, 2022. Client #3 was admitted on September 22, 2022 and still active at the time of the inspection. A case consultation was due to be completed no later than November 22, 2022, but was not completed until February 14, 2023.A case consultation was due to be completed no later than April 14, 2023, but was not completed at the time of the inspection.Client #4 was admitted on May 19, 2023 and still active at the time of the inspection. A case consultation was due to be completed no later than July 19, 2023, but was not completed at the time of the inspection.Client #5 was admitted on October 25, 2022 and still active at the time of the inspection. A case consultation was due to be completed no later than January 9, 2023, but was not completed until January 13, 2023.Client #6 was admitted on April 1, 2023 and still active at the time of the inspection. A case consultation was due to be completed no later than June 1, 2023, but was not completed at the time of the inspection.This is a repeat citation from the August 16, 2022 annual licensing inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Manager has amended the procedure for the completion of case consultations. Going forward, Case Consultaions will be completed at the time of treatment plan reviews, which is every 60 days. The Facility Manager will work with the EHR team to set up case consultation reminders to accompany the treatment plan review reminders. These reminders will be generated by the EHR and sent via message to the therapists on a weekly basis. Due dates will also appear on the therapist's weekly calendar in the EHR.
The Facility Director will schedule quarterly peer reviews of client files to ensure compliance to the plans of correction.
Results of the peer reviews will be discussed quarterly in Drug and Alcohol Team Meetings.
Any lapses in compliance will be addressed via a coaching session with Drug and Alcohol staff. |
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 applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in one of one client records. The policy and procedure manual indicates follow-up contact must be within 30 days after discharge.Client #1 was admitted on February 7, 2023 and discharged on April 6, 2023. Follow-up was to be completed no later than May 6, 2023, but was not completed at the time of the inspection. This is a repeat citation from the August 16, 2022 and October 20, 2021 annual licensing inspections.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Manager has amended the follow up policy in the Procedure Manual. A follow up survey has been created and will be mailed to the client at the time of dicharge. The client's discharge summary will note the date of the mailing and any response to the survey will be uploaded to the EHR by the front desk staff with the results shared with the therapist and Project Manager.
The Facility Director will schedule quarterly peer reviews of client files to ensure compliance to the plans of correction.
Results of the peer reviews will be discussed quarterly in Drug and Alcohol Team Meetings.
Any lapses in compliance will be addressed via a coaching session with Drug and Alcohol staff. |
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 a review of client records, the facility failed to comply with plans of correction that were approved by the Department.A plan of correction for completing follow-up contact with clients was submitted and approved by the Department for the August 16, 2022 and October 20, 2021 annual licensing inspections. Follow up contact was again found to be a deficiency in the July 20, 2023 annual licensing inspection.This was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will review all Plans of Correction with the Drug and Alcohol staff on an annual basis.
The Facility Director will schedule quarterly peer reviews of client files to ensure compliance to the plans of correction.
Results of the peer reviews will be discussed quarterly in Drug and Alcohol Team Meetings.
Any lapses in compliance will be addressed via a coaching session with Drug and Alcohol staff. |