INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 4, 2024 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(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of administrative information, the facility failed to ensure CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations.
Staff #1 had CPR certification that expired in November 2023. There are no other staff at the facility with CPR certification. The facility failed to ensure CPR certification was provided to a sufficient number of staff persons from December 2023 through the date of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director and Clinical Director will idenitfy CPR and First Aid training resources for staff. Training will be completed by enough staff to insure that at least one staff member who is trained in CPR and First Aid are onsite during PERSAD's hours of operation. CPR and First Aid Training will be completed by December 31, 2024. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the personnel training records, the facility failed to have the project director complete at least 12 clock hours of annual training in one of one record.
Staff #1 was hired as the project director on April 12, 2021. Staff #1 had documented zero hours of training for the July 1, 2023 through June 30, 2024 training year.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Facility Director will review annual training plan and training requirements in supervision by October 29, 2024. The Facility Director will identify, register, and complete 12 hours of training by February 28, 2025, the Clinical Licensing renewal deadline. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on review of the facility policy and procedure manual, the facility failed to provide documentation of the project director preparing, annually updating, and signing a written manual delineating project policies and procedures. The policy and procedure manual was not annually updated by signature since January 18, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will request that the Executive Director and the PERSAD Board President review the Drug and Alcohol Procedure Manual and sign off on the review sheet by October 31, 2024. The signed form will then be placed at the first page of the Drug and Alcohol Program Manual.
For 2025, the Facility Director will review and update the Drug and Alcohol Policy and Procedure Manual by November 30, 2025. The Facility Director will request that the Executive Director and PERSAD Board President review and sign the Drug and Alcohol Procedure Manual Update Form at the December 2025 board meeting. The Facilty Director will then review the signed form and place it as the first page of the Policy and Procedure Manual. |
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.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in two of four applicable records.
Client #2 was admitted on November 14, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on December 14, 2023. A treatment and rehabilitation plan update was due no later than February 14, 2024, but was not completed until March 9, 2024.
Client #4 was admitted on March 18, 2024 and was discharged on August 31, 2024. A treatment and rehabilitation plan was developed on April 4, 2024. A treatment and rehabilitation plan update was due no later than June 4, 2024, but was not completed until June 26, 2024.
A treatment and rehabilitation plan was developed on June 26, 2024. A treatment and rehabilitation plan update was due no later than August 26, 2024, but was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director will review the policy and procedures for Treatment Plan reviews and updates with the Drug and Alcohol Clinician by October 31, 2024.
PERSAD's Electronic Medical Record notifies the clinician of the identified client and the due date of their review. The name of the client and the due date appear on the clinician's weekly calendar.
The Facility Director will review each of the Drug and Alcohol client's files monthly to ensure that the treatment plans and updates have been completed within the 60 day time frame.
If a plan is not completed by the time of the file review the Facility Director will review the due dates with the clinician and have the clinician complete the review in their weekly clinical supervision meeting. |
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 client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in two of four applicable records. The facility policy and procedure manual indicate a case consultation will occur every sixty days.
Client #2 was admitted on November 14, 2023 and was still active at the time of the inspection. A case consultation was due to occur no later than March 16, 2024, however this was not completed at the time of the inspection.
Client #4 was admitted on March 18, 2024 and was discharged on August 31, 2024. A case consultation was due to occur no later than May 18, 2024, however this was not completed at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
This is a repeat citation from the July 20, 2023 and August 16, 2022 annual licensing inspections.
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Plan of Correction
The Facility Director will review the policy and procedures for the completion of Case Consultations with the Drug and Alcohol Clinician by October 31, 2024.
PERSAD's Electronic Medical Record notifies the clinician of the identified client and the due date of their treatment plan review. The name of the client and the due date appear on the clinician's weekly calendar. The Facility Director will instruct the Clinician to complete the Case Consultation on the same date that the treatment review is done.
The Facility Director will review each of the Drug and Alcohol client's files monthly to ensure that the case consultations have been completed within a 60 day time frame.
If a case consulation is not completed by the time of the file review, the Facility Director will review the due dates with the clinician and have the clinician complete the case consultation in their weekly clinical supervision meeting. |
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 case consultations was submitted and approved by the Department for the July 20, 2023 and August 16, 2022 annual licensing inspections. Case consultations were again found to be a deficiency in the September 4, 2024 annual licensing inspection.
This was reviewed with the facility staff during the licensing process.
This is a repeat citation from the July 20, 2023 annual licensing inspection.
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Plan of Correction
The Facility Director will review the past plans of correction with Drug and Alcohol Clinician. The Facility Director will review the risk to PERSAD's annual license renewal if PERSAD is found to be out of compliance with any/all Plan(s) of Correction by October 31, 2024.
The Facility Director will review files on a monthly basis to ensure that the plans of correction are being followed. If there are lapses in the compliance with the Plan of Correction a coaching session will be held with the Clinical Director, Facility Director and Drug and Alcohol Treatment staff.
To avoid further non-compliance with Plans of Correction, the Facilty Director will follow the submitted plan of correction for treatment reviews as it appears in the plan of correction for Observations #1883 which is repeated below.
The Facility Director will review the policy and procedures for the completion of Case Consultations with the Drug and Alcohol Clinician by October 31, 2024.
PERSAD's Electronic Medical Record notifies the clinician of the identified client and the due date of their treatment plan review. The name of the client and the due date appear on the clinician's weekly calendar. The Facility Director will instruct the Clinician to complete the Case Consultation on the same date that the treatment review is done.
The Facility Director will review each of the Drug and Alcohol client's files monthly to ensure that the case consultations have been completed within a 60 day time frame.
If a case consulation is not completed by the time of the file review, the Facility Director will review the due dates with the clinician and have the clinician complete the case consultation in their weekly clinical supervision meeting. |