INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 1-3, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Cen-Clear, 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:
|
Plan of Correction
|
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
|
Observations
Based on a review of the fire drill records, the facility failed to maintain a written fire drill record that includes documentation of problems encountered.
Fire drill records were reviewed from April 2022 to March 2023. Fire drills documented from April 2022 through October 2022, December 2022, February 2023 and March 2023 did not include problems encountered.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The form being utilized by the entity contracted to perform fire-drills contained a section for comments with the heading "Tech Notes." When no problems or issues were encountered, no documentation was being entered into this portion of the form.
This form has been revised and this field updated from "Tech Notes" to "Problems Encountered," and has been made a mandatory field. Education occurred with the contracted entity on 4/12/23 that documentation should reflect any issues encountered during the drill, and/or, when no issues are encountered. This implementation was completed for implementation in May, 2023. Fire Drills will be audited by the third week of each month by Outpatient Director to ensure compliance with all aspects of regulatory requirements and request that drills be re-performed and appropriately documented by end of the month in instances where continued deficiencies are identified.
|
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on a review of client records, the facility failed to document the disclosure of the criteria for admission to the client in seven of seven records.
Neither the handbook nor the documentation the clients sign at intake includes the criteria for admission.
These findings were reviewed with facility staff during the licensing process
|
Plan of Correction
709.91: The SUD Welcome packet provided to all consumers at the time of admission has been revised to include criteria for admission, treatment, completion, and discharge. Welcome packets are provided to all consumers as part of their intake, and written attestation to this effect is obtained during the intake appointment in the "Multi-Consent" documentation. This change will take effect on 5/1/23. Facility Directors and Clinical Supervisors have been made aware of this change, and all active consumers will be provided a copy of the revised SUD Welcome Packet which clearly outlines these criterion. Quality Assurance will, as part of their ongoing monthly quality monitoring, ensure that a valid and signed multi-consent is on-file indicating that consumers received a copy of the revised SUD Welcome Packet. These findings will be reviewed with Regional Managers for follow-up when deficiencies are identified. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to update treatment plans within 60 days in four of seven records reviewed.
Client #2 was admitted on August 24, 2022 and discharged on February 23, 2023. The treatment plan update was due on December 30, 2022 and not completed until January 11, 2023.
Client #3 was admitted on October 10, 2022 and discharged on March 7, 2023. The treatment plan update was due on November 9, 2022 but not completed until November 22, 2022.
Client #4 was admitted on December 8, 2022 and discharged on April 4, 2023. The treatment plan update was due on February 6, 2023 but not completed until February 23, 2023.
Client #5 was admitted on December 19, 2022 and still an active client at time of inspection. The treatment plan update was due on January 18, 2023 but not completed until January 26, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
These findings were reviewed with our Quality Assurance Department and Regional Management Staff on 5/3/2023. Findings will be discussed with all staff during monthly department meeting on 6/5/2023. Quality Assurance will review records from all staff and sites and assess for timeliness of treatment plans. Findings will be presented to Director of OP and Regional Management staff as they are compiled. Regional Managers will notify Clinical Supervisors assigned to the staff person in each instance where a treatment plan is not completed in a timely fashion so additional education and training can be provided. To aide in documentation prioritization, Clinical Supervisors will also use facility's EHR reporting functionality to provide staff with a list of documentation due each Monday. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to provide treatment according to the treatment plans in three of seven records reviewed.
Client #1 was admitted on September 8, 2022 and discharged on March 13, 2023. The treatment plan completed on November 8, 2022 stated client should receive individual one time a week, outpatient group one time a week and intensive outpatient group two times a week. The client only received individual once a week and one outpatient group per week until the following treatment plan was completed on December 15, 2022.
Client #2 was admitted on August 24, 2022 and discharged on February 23, 2023. The treatment plan completed on October 31, 2022 stated client should receive individual one time a week, outpatient group one time a week, and intensive outpatient group two times a week. The client only received individual once a week and one outpatient group per week until the following treatment plan was completed on January 11, 2023.
Client #3 was admitted on October 10, 2022 and discharged on March 7, 2023. The treatment plan completed on November 22, 2022 stated client should receive individual one time a week, outpatient group two times a week, and intensive outpatient group three times a week. The client only received individual once a week and two outpatient groups per week until the following treatment plan was completed on January 10, 2023.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
These findings were reviewed with Quality Assurance and Regional Management staff during a regional meeting on 5/3/2023. As demonstrated during the onsite review, this is the result of an error in the Electronic Health Record that resulted in inaccurate information being carried forward on treatment plans following transition from 2.1 to 1.0 services. Staff will be educated on the need to adjust their documentation practices to ensure treatment plans contain correct and accurate information regarding the types and frequency of services during a departmental meeting scheduled 6/5/2023. Regional Management and Clinical during this meeting, Clinical Supervisors will be instructed to review treatment plans during the approval process to ensure revisions are reflected in the type and frequency sections prior to approval and provide real-time feedback in instances where these errors persist. |