INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 13-14, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Arc Manor 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on the review of personnel records, the facility failed to ensure clinical supervisor completed a core curriculum in clinical supervision within a timely fashion.
Employee #3 was promoted to a clinical supervisor position on July 1, 2023, and was still in that position at the time of the inspection. There was no documentation of the employee completing the core curriculum at the time of the onsite.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive director will ensure that an individual who gets promoted to clinical director/supervisor will take the approved DDAP Clinical Supervisor Training. If the training is not available, executive director will contact DDAP for prior approval for a training that is not provided by the Department. Employee #3 will attempt to take the DDAP clinical supervision training within the year as the training employee did take was not approved by the Department. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ventilate toilets and wash rooms by an exhaust fan or window. The exhaust fans in the first and second floor men's and women's bathroom were inoperable.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The part for the exhaust fan has arrived which was ordered by maintenance 30 days ago. Maintenance will fix exhaust fans on 03/28/2024. Maintenance will then check exhaust fans over the next month to ensure they are properly working. Maintenance will then check exhaust fans on annual inspection of the building and will report concerns to executive director. Regular inspection will be completed weekly by clinical assistant on general walk through of the facility on 03/29/2024 and will report to clinical assistant supervisor and executive director of any concerns. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. It was observed that the first shower in the second-floor men's bathroom/shower appeared to have a black mold like substance on the shower wall and floor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
This information was reviewed with clinical assistant supervisor. The observation was reviewed in clinical assistant staff meeting on 03/26/2024. Regular inspection of shower stalls will be added to the clinical assistant check list for residential center general daily walk through completed by clinical assistant. Any concerns should be reported to clinical assistant supervisor who will contact maintenance. This will be implemented on 03/29/2024. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical site inspection, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor.
One of two fire extinguishers located in the second floor kitchen was not secured to the wall.
This finding was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The observation was corrected on 03/14/2024 by maintenance. Clinical assistants will regularly check that fire extinguishers are secured to the wall on regular residential walk through of the center. Any issues or concerns will be reported to clinical assistant supervisor and clinical assistant supervisor will contact maintenance to correct issue. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility's Staffing Requirement Facility Summary Report and the facility's training information, the facility failed to ensure three employees received the required training in the use of the fire extinguishers upon employment.
Employee #7 was hired on February 21, 2023, for the position of counselor and was still employed at the time of the inspection. The facility had no documentation to verify that this employee had been trained to properly operate a fire extinguisher.
Employee #9 was hired on January 19, 2024, for the position of counselor assistant and was still employed at the time of the inspection. The facility had no documentation to verify that this employee had been trained to properly operate a fire extinguisher.
Employee #10 was hired November 6, 2023, for the position of counselor assistant and was still employed at the time of the inspection. . The facility had no documentation to verify that this employee had been trained to properly operate a fire extinguisher.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training employees on how to operate a fire extinguisher will be added to the Annual Safety Training. This training is completed for new hires and completed annual. Safety Committee Chair will add a slide to the power point training that will instruct employees on how to operate a fire extinguisher. A supervisor will then train new hires on how to operate a fire extinguisher and then sign off on the Annual Safety Training Quiz that this was completed. This will be implemented on 03/25/2024. Safety Committee Chair will train all staff on how to operate a fire extinguisher by 04/11/2024. Employees 7, 9, and 10 will be trained on 03/28/2024 to operate fire extinguisher by visual observation and the PASS technique by safety committee chair. |
709.28 (c) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to: name of the person, agency or organization to whom disclosure is made. This was observed in ten out of fourteen client records reviewed.
Client #1 was admitted on March 4, 2024, and was still active at the time of the inspection. A consent, for case management, was completed on March 4, 2024, that did not specify to whom the disclosure was to be made.
Client #2 was admitted on February 26, 2024, and was still active at the time of the inspection. A consent, for a primary care physician, was completed on February 26, 2024, that did not specify to whom the disclosure was to be made.
Client #3 was admitted on January 29, 2024, and was still active at the time of the inspection. A consent, for a primary care physician, was completed on January 29, 2024, that did not specify to whom the disclosure was to be made.
Client #4 was admitted on was admitted on October 20, 2023, and was discharged on December 11, 2023. A consent, for a primary care physician, was completed on October 20, 2023, that did not specify to whom the disclosure was to be made.
Client #5 was admitted on was admitted on October 9, 2023, and was discharged on October 17, 2023. A consent, for a primary care physician, was completed on October 9, 2023, that did not specify to whom the disclosure was to be made.
Client #6 was admitted on was admitted on January 22, 2024, and was discharged on February 16, 2024. A consent, for a primary care physician, was completed on January 22, 2024, that did not specify to whom the disclosure was to be made.
Client #8 was admitted on was admitted on January 30, 2024, and was still active at the time of the inspection. A consent, for a primary care physician, was completed on January 30, 2024, that did not specify to whom the disclosure was to be made.
Client #9 was admitted on was admitted December 11, 2023, and was still active at the time of the inspection. A consent, for a primary care physician, was completed on December 11, 2023, that did not specify to whom the disclosure was to be made.
Client #11 was admitted on was admitted on December 13, 2023, and was discharged on February 21, 2024 A consent, for a primary care physician, was completed on December 13, 2023, that did not specify to whom the disclosure was to be made.
Client #12 was admitted on was admitted on September 20, 2023, and was discharged on November 16, 2023. A consent, for a primary care physician, was completed on September 20, 2023, that did not specify to whom the disclosure was to be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The executive director reviewed information with clinical director. The Clinical Director will review the requirements of completing these releases of information prior to beginning treatment with clinical staff on 4/11/2024. The CFO will also review this information with administrative assistant staff at the integration meeting on 4/16/2024. The Clinical Director will conduct file reviews monthly to ensure these forms are completed starting 4/11/2024.
Clinician will complete new consent with client #1 by 04/05/2024. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of residential client records, the facility failed to document a follow-up contact within guidelines established by the facility's policy and procedures manual in one out of one applicable record reviewed. The facility's policy and procedures manual states that follow-up contacts will occur one month and six months after a client has been discharged.
Client #4 was admitted on October 20, 2023, and was discharged on December 11, 2023. The initial follow-up contact was due no later than January 11, 2024; however, it was not documented until January 24, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The information was reviewed with Engagement Specialist on 03/27/2024. The policy will be updated to include a 10 day grace period by 04/08/2024.Engagement specialist will run discharge reports monthly to ensure that she has information to make all contacts for follow-up. These will be put into a binder so that engagement specialist can monitor up coming dates weekly to ensure that follow ups are completed in the policy time frame. This will be 04/01/2024. |
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 outpatient client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client that includes written documentation of type and frequency of treatment and rehabilitation. This was observed in five out of seven client records reviewed.
Client #8 was admitted on January 30, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was developed on February 6, 2024, it did not specify the frequency of each treatment activity.
Client #9 was admitted December 11, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on December 18, 2023, it did not specify the frequency of each treatment activity.
Client #10 was admitted on February 29, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was developed on February 29, 2024, it did not specify the frequency of each treatment activity.
Client #11 was admitted on December 13, 2023, and was discharged on February 21, 2024. A comprehensive treatment plan was developed on January 2, 2024, it did not specify the frequency of each treatment activity.
Client #12 was admitted on September 20, 2023, and was discharged on November 16, 2023. A comprehensive treatment plan was developed on September 29, 2023, it did not specify the frequency of each treatment activity.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The information was reviewed with clinical director on 03/15/2024. Clinical director trained clinicians in a staff meeting on 03/21/2024 to specify frequency for each treatment activity. Supervisors will monitor treatment plans effective 03/28/2024 to ensure that clinical staff is consistently specifying frequency for each treatment activity.
Clients #8, #9, and #10 will have their treatment plans updated to include this information by 04/13/2024. |
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 a review of outpatient client records, the facility failed to document a follow-up contact within guidelines established by the facility's policy and procedures manual in two out of four applicable records reviewed. The facility's policy and procedures manual states that follow-up contacts will occur one month and six months after a client has been discharged.
Client #12 was admitted on September 20, 2023, and was discharged on November 16, 2023. The initial follow-up contact was due no later than December 16, 2023; however, it was not documented until December 27, 2023.
Client #14 was admitted October 4, 2023, and was discharged on November 13, 2023. The initial follow-up contact was due no later than December 13, 2023; however, it was not documented until December 27, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The information was reviewed with Engagement Specialist on 03/27/2024. The policy will be updated to include a 10 day grace period by 04/08/2024.Engagement specialist will run discharge reports monthly to ensure that she has information to make all contacts for follow-up. These will be put into a binder so that engagement specialist can monitor up coming dates weekly to ensure that follow ups are completed in the policy time frame. This will begin 04/01/2024. |