INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Adappt Outpatient Treatment Service 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)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee's #3 received the minimum of 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee #3 was hired as a counselor on November 12, 2018 and was due to have the communicable disease trainings no later than November 12, 2019. There was no documentation in the personnel file of the completion of the HIV/AIDS training at the time of the inspection.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Facility Director will ensure all staff receive required hours of HIV/AIDS and tuberculosis, sexually transmitted diseases and other health topics within the first year of employment. Current employees are scheduled for training by the end of April, 2020. Project Director will review training completed semi-annually. |
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.
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Observations
Based on a review of fire drills from January 2019 until January 2020, the facility failed to include the exit routes used during fire drills as well as if the fire alarm or smoke detector was operative.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Project Director will train Facility Director and assigned personnel on conducting and documenting fire drills by 3/27/20. Project Director will observe fire drill documentation semi-annually to ensure compliance.
Facility Director will obtain verification from the building owner the fire alarms have been tested and are in working condition. Project Director will observe verification semi-annually. |
709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the incident of Physical assault or sexual assault by staff or a client.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to a physical assault or sexual assault by staff or a client. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the incident of Selling or use of illicit drugs on the premises.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to selling or use of illicit drugs on the premises. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the incident of Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the incident of Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the incident of Theft, burglary, break-in or similar incident at the facility
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to theft, burglary, break-in or similar incident at the facility. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the incident of Event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to event at the facility requiring the presence of police, fire or ambulance personnel. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the incident of Fire or structural damage to the facility
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures for responding to fire or structural damage to the facility. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to the incident of Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on documenting, developing and implement a responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(1) Documentation of the unusual incident.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to include the documentation of the unusual incident.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on documentation of the unusual incident. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to include the Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on prompt review and identification of the causes directly or indirectly responsible for the unusual incident. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to include the Implementation of a timely and appropriate corrective action plan, when indicated.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures on implementing a timely and appropriate corrective action plan in response to unusual incidents. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on a review of the policy and procedure manual, the facility failed to develop and implement policies and procedures to include the Ongoing monitoring of the corrective action plan
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Project policy and procedure manual was amended to include procedures of ongoing monitoring of the corrective action plan in response to unusual incidents. Project Director will train Facility Directors on procedure by 3/13/20. Facility Directors will train personnel on procedure by 3/27/20. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, #1,2,3 and 4, the facility failed to document a psychosocial evaluations in client records as of the date of the licensing inspection.
Client #1 was admitted on November 19, 2019 and was still an active client at the time of the inspection.
Client #2 was admitted on November 11, 2019 and was still an active client at the time of the inspection.
Client #3 was admitted on September 19, 2019 and was still an active client at the time of the inspection
Client #4 was admitted on November 25, 2019 and was still an active client at the time of the inspection. .
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
The psychosocial evaluation form will include an additional section for the counselor to document his/her overall evaluation of the information and an assessment of treatment based on the evaluation. The Facility Director will add the section to the evaluation and train staff on it by 3/31/20. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of seven client records, the facility failed to include type and frequency of treatment and rehabilitation services in the comphrensive treatment plans in all seven client record.
These findings were discussed with the facility staff during the inspection process.
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Plan of Correction
Counselors will complete a treatment plan update when the frequency of a participant's Individual Treatment Sessions changes. These treatment plan updates will reflect whether the participant will be scheduled for an individual session: weekly, every other week, or other scheduled occurrence. Facility Director will conduct monthly audits of participant files to ensure compliance. Facility Director will train counselors by 3/13/20. |
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 a review of seven client records, the facility failed to document treatment plan updates within the regulatory timeframe in four client records reviewed.
Client #3 was admitted on September 19, 2019 and was still active at the time of the inspection. A treatment plan update was completed on December 13, 2019 and the next update was due no later than February 13, 2020 ; however, there was no update documented in the record at the time of the inspection.
Client #5 was admitted on August 26, 2019 and was discharged on December 13, 2019. A treatment plan update was completed on September 20, 2019 and the next update was due no later than November 20, 2019; however, there was no update documented in the record at the time of the inspection.
Client #6 was admitted on July 25, 2019 and was discharged on December 17, 2019 . A treatment plan update was completed on September 6, 2019 and the next update was due no later than November 6, 2019 ; however, there was no update documented in the record at the time of the inspection.
Client #7 was admitted on May 10, 2019 and was discharged on November 19, 2019 . A treatment plan update was completed on June 26, 2019 and the next update was due no later than August 26, 2019; however, there was no update documented in the record at the time of the inspection.
These findings were discussed with facility staff during the inspection process
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Plan of Correction
Facility Director will review the treatment plans with counselors to include updates on the frequency of individual sessions when completing the treatment plan updates by 3/13/20. Facility Director will conduct monthly chart audits to ensure compliance. |
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.
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Observations
Based on a review of seven outpatient client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in four charts reviewed.
Client #1 was admitted on November 19, 2019 and was still active at the time of the inspection. The inital treatment plan , dated December 4, 2019 , indicated two group sessions per week and one individual session per week. The chart's record of service and progress notes indicated that the client had received no group sessions between January 9-28th and January 30-February 4th. The client had not recieved an individual session since January 8, 2020.
Client #2 was admitted on November 11, 2019 and was still active at the time of the inspection. The intial treatment plan, dated November 11, 2019, indicated 2 group sessions per week and 1 individual session per week. The chart's record of service and progress notes indicated that the client had received no group sessions from December 14-January 2nd, 2020 and no individual sessions from December 13-January 2nd, 2020.
Client #5 was admitted on August 26, 2019 and was discharged on December 13, 2019. The inital treatment plan, dated September 6, 2019 , indicated 1 individual session per week. The chart's record of service and progress notes indicated that the client had received no individual sessions for the week of September 23-28, September 29-October 5, 2019, October 17-November 16, 2019 and November 18th- December 17, 2019.
Client #6 was admitted on July 25, 2019 and was discharged on December 17, 2019. The intial treatment plan, dated July 30, 2019 , indicated 2 group sessions per week and one individual session per month. The chart's record of service and progress notes indicated that the client had received no group sessions for the months of November 2019 and no individual sessions between September 17-November 19th, 2019.
These findings were discussed with facility staff during inspection process.
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Plan of Correction
Counselors will document when a client does not attend a scheduled event or individual session. Facility Director will conduct monthly chart audits to ensure compliance. Facility Director will train counselors by 3/13/20 |
709.93(a) 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:
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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 progress notes,complete record of service, discharge summaries, aftercare plans, case consultation notes, and follow-up information in client record #'s 1, 2, 3, 4, 5, 6, and 7.
Client #1 was admitted on November 19, 2019 and was still active at the time of the inspection. The client record did not contain documentation of completed record of service and group/individual progress notes.
Client #2 was admitted on November 11 2019 and was still active at the time of the inspection. The client record did not contain documentation of completed record of service and group/individual progress notes.
Client #3 was admitted on September 19, 2019 and was still active at the time of the inspection. The client record did not contain documentation of case consults and group/individual progress notes.
Client #4 was admitted on November 25, 2019 and was still active at the time of the inspection. The client record did not contain documentation of case consults and group/individual progress notes.
Client #5 was admitted on August 26, 2019 and was discharged on December 13, 2019. The client record did not contain documentation of case consults, group/individual progress notes, aftercare plan, and discharge summary.
Client #6 was admitted on July 25, 2019 and was discharged on December 17, 2019. The client record did not contain documentation of case consults and group/individual progress notes.
Client #7 was admitted on May 10, 2019 and was discharged on November 11, 2019. The client record did not contain documentation of case consults and group/individual progress notes, follow up and aftercare plan.
This is a repeat citation. The facility was previously cited for noncompliance with this standard during the licensure inspections conducted on February 22, 2019, May 8, 2018 and January 14, 2019.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Facility Director and counselors will revise file audit check list to ensure proper client record compliance. Counselors will create a checklist to ensure that the case consults are completed within the specific timeframe. Facility Director will conduct monthly chart audits to ensure compliance. Facility Director will train counselors by 3/13/20. |