INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 25, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial House Outpatient 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from May 2024 - February 2025, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of August and September 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The policy regarding monthly fire drills was reviewed with the Outpatient Program Director. All requirements such as documentation of time, exits and methods were reviewed. The Operations Director will complete random audits of facility fire drill logs to ensure compliance.
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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 the May 2024 - February 2025 fire drill logs, the facility failed to document the amount of time it took to evacuation during the January 27, 2025, fire drill.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The policy regarding monthly fire drills was reviewed with the Outpatient Program Director. All requirements such as documentation of time, exits and methods were reviewed. The Operations Director will complete random audits of facility fire drill logs to ensure compliance.
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709.91(b)(7) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within facility timeframes in three out of seven records reviewed. The facility's policy and procedures manual states that the preliminary treatment plan must be completed by the second treatment session.
Client #4 was admitted on June 24, 2024, and discharged on October 7, 2024. There was no documentation in the client record that a preliminary treatment plan had been completed.
Client #6 was admitted on August 7, 2024, and discharged on December 10, 2024. There was no documentation in the client record that a preliminary treatment plan had been completed.
Client #7 was admitted on October 31, 2024, and discharged on December 31, 2024. There was no documentation in the client record that a preliminary treatment plan had been completed.
This is a repeat citation from the April 17, 2024 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Outpatient Program Director will be responsible for re-training clinical staff on current policy associated with preliminary treatment plan development. This training is scheduled to occur during staff meeting on Thursday 4/17/2025. In addition, Quality Assurance Manager will ensure compliance through routine chart audits. |
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 the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in seven out of seven client records reviewed.
Client #1 was admitted on October 1, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was developed on December 19, 2024, that did not specify type or frequency of treatment services.
Client #2 was admitted on October 8, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was developed on December 4, 2024, that did not specify type or frequency of treatment services.
Client #3 was admitted on September 6, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 11, 2024, did not specify type or frequency of treatment services.
Client #4 was admitted on June 24, 2024, and discharged on October 7, 2024. A comprehensive treatment plan was developed on July 24, 2024, did not specify type or frequency of treatment services.
Client #5 was admitted on September 4, 2024, and discharged on November 15, 2024. A comprehensive treatment plan was developed on November 4, 2024, did not specify type or frequency of treatment services.
Client #6 was admitted on August 7, 2024, and discharged on December 10, 2024. A comprehensive treatment plan was developed on September 4, 2024, did not specify type or frequency of treatment services.
Client #7 was admitted on October 31, 2024, and discharged on December 31, 2024. A comprehensive treatment plan was developed on November 7, 2024, did not specify type or frequency of treatment services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient Program Director will be resposible for re-training clinical staff on treatment plan documentation associated with type and frequency of services. This training is scheduled to occur during staff meeting on Thursday May 8th 2024. In addition, Quality Assurance Manager will ensure ongoing compliance through chart audits. |
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 client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six applicable records reviewed.
Client #1 was admitted on October 1, 2024, and was still active at the time of the inspection. A treatment plan was completed on December 19, 2024, and the next update was due no later than February 19, 2025; however, the next update was completed on February 24, 2025.
Client #3 was admitted on September 6, 2024, and was still active at the time of the inspection. A treatment plan was completed on October 11, 2024, and the next update was due no later than December 11, 2024; however, it was completed on December 18, 2024.
Client #4 was admitted on June 24, 2024, and discharged on October 7, 2024. A treatment plan was completed on July 24, 2024, and the next update was due no later than September 24, 2024; however, there were no further treatment plan updates documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Outpatient Program Director will be resposible for re-training clinical staff on current policy associated with timely documentation of treatment plan updates. This training is scheduled to occur during staff meeting on Thursday May 8th 2025. In addition, Quality Assurance Manager will assure compliance during routine chart audits. |
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 client records, the facility failed to provide a complete client record, which is to include follow-up information, in four out of four discharged records reviewed. The facility's policy is to follow-up with all clients, except for those that are incarcerated, within thirty days of discharge.
Client #4 was admitted on June 24, 2024, and discharged on October 7, 2024. There was no documentation of a follow-up contact in the client record.
Client #5 was admitted on September 4, 2024, and discharged on November 15, 2024. There was no documentation of a follow-up contact in the client record.
Client #6 was admitted on August 7, 2024, and discharged on December 10, 2024. There was no documentation of a follow-up contact in the client record.
Client #7 was admitted on October 31, 2024, and discharged on December 31, 2024. There was no documentation of a follow-up contact in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Outpatient Program Director will review the policy and procedure for follow up calls with the Office Manager by 4/24/2025. Office Manager will proceed with executing policy and procedure as written, inclusive of clients included in this audit. Quality Assurance Manager will conduct random audits to ensure ongoing compliance with the process. |