INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 26-27, 2019, by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection Clinical Outcomes Group Incorporated was found to not 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
During a review of fire drill records on February 26-27, 2019, it was found that the facility failed to document if any problems were encountered and whether the fire alarm or smoke detector was operative.
Fire drill records from January 18, 2018 through December 21, 2018 failed to document if any problems were encountered during the fire drill.
Fire drill records from January 18, 2018 through December 21, 2018 failed to document whether the fire alarm or smoke detector was operative during the fire drill.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The facility director will meet with the emergency response individual to review fire drill documentation by March 1, 2019. The emergency response individual will create a new form to include problems that occurred during fire drill and what means were used to announce the fire drill. This new form will be created for use by 3/15/19. The facility director will follow up with the emergency response individual to ensure form completion by 3/18/19. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
During a review of the fire drill record on February 26-27, 2019, it was found that the facility failed to document which fire alarm or smoke detector was set off during each fire drill.
Fire drill records from January 18, 2018 through December 21, 2018, failed to document which fire alarm or smoke detector was set off during each fire drill.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The facility director will write a letter to DDAP requesting a waiver to use alternative methods to announce future fire drills. This will be completed by 3/1/2019.
Once DDAP approves the request, the facility director will meet with the emergency response individual to choose a method to announce fire drills. This will be decided by 3/18/2019.
The emergency response individual will document on the new form what method was used to announce the fire drills. This will occur by 3/30/2019. |
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.
|
Observations
While reviewing client records during an onsite visit on February 26-27, 2019, the facility failed to document type and frequency of treatment and rehabilitation services.
Client #10 was admitted on July 11, 2018 and was still active at the time of the inspection. Treatment plans dated November 9, 2018 and January 9, 2019 did not indicate the frequency of individual counseling.
Client #11 was admitted on January 19, 2018 and was still active at the time of inspection. Treatment plans dated November 30, 2018 and January 30, 2019 did not indicate the type or frequency of counseling.
Client # 12 was admitted on November 27, 2018 and was discharged on February 8, 2019. Treatment plans dated November 27, 2018 and December 17, 2018 did not indicate the type or frequency of counseling.
Client #13 was admitted on July 29, 2016 and was discharged on February 21, 2019. Treatment plans dated November 30, 2018 and January 31, 2019 did not indicate type or frequency of counseling.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The facility director will review with all staff the comprehensive treatment plan requirements in our bi-monthly supervision by 3/06/2019. A new treatment plan is currently being used in our electronic health records which requires all staff to document frequency and type of counseling.
The facility director will meet with the counselors of client #11, client # 12, client #13 & client #14 to make sure that appropriate addendums are completed to ensure compliance. Each counselor will be required to document the type and frequency of counseling their client will receive.
The facility will be in full compliance as of 3/30/2019. |