INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 29, 2020 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, WES Corporation 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(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on review of the facility policy and procedure manual on January 29, 2020, the facility failed to develop a policy and procedure indicating who is responsible and the time frames for completion of the assessment of staff training needs, overall plan for addressing these needs, mechanism to collect feedback on completed training, and annual evaluation of the overall trainng plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director and WES Director of Quality management shall develop a comprehensive Staff Training policy and procedure and implement such by 4/1/2020. |
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 review of personnel records on January 29, 2020, the facility was unable to provide a sufficient number of staff persons trained in CPR certification onsite during the project ' s hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The WES Training coordinator shall schedule and provide CPR training for all current staff by 9/1/2020. The WES training coordinator shall schedule all new staff for CPR training within the first 90 days of employment with WES. The WES training coordinator and the Project Director shall both track that training is complete.
The Project Director shall arrange the schedule so at least 3 staff trained in CPR are at work each day. In the event that all CPR certified staff are out, the Project Director will arrange for a WES CPR trained staff member that works at the same site to be available in the event CPR is needed. |
705.28 (a) (1) (ii) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
During a physical plant inspection on January 29, 2020, the facility failed to maintain two exits on every floor separated by a minimum distance of 15 feet. The second floor of the building where counseling offices and group rooms are located had only one exit available.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Quality Management Director shall make an additional exit available to the program area by 4/1/2020. |
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 facility fire drill log on January 29, 2020, the facility failed to document any problems that may have occurred during the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Quality Management shall modify the fire drill log to include documentation of any problems that may have occurred during scheduled fire drills by 3/15/2020. |
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 a review of the project ' s policy and procedure manual on January 29, 2020, the project director failed to provide documentation of an annual review and update of the policy and procedure manual.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Project Director shall complete an annual review of Policy and Procedure manual and store in the Policy and Procedure manual. The review shall include review of all policies and documentation of updates to policies and procedures. This will be completed by 4/1/2020.
Going forward the Facility Director and Project Director shall complete the annual review of the Policy and Procedure Manual by the end of the calendar year. After the review completed by 4/1/2020 the next review shall be completed by 12/31/2020. |
709.24 (a) (1) MEMO Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(1) Definition of the target population toward whom facility services are directed.
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Observations
Based on review of the project ' s policy and procedure manual on January 29, 2020, the facility to provide documentation of a written plan to include the definition of the target population toward whom facility services are directed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Project Director shall develop a written plan that identifies the target population served by the program and will store such in the Policies and Procedures manual. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on review of the project ' s policy and procedure manual on January 29, 2020, the facility to provide documentation of a written plan to include the written procedures for the management of treatment/rehabilitation services for clients.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Project Director shall develop and implement a Policy and Procedure that identifies the procedures for management of treatment. |
709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
Based on review of the project ' s policy and procedure manual on January 29, 2020, the facility failed to provide documentation of a written policy and procedure to include the written procedures for the supervision of staff.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Facility Director and Project Director shall develop and implement a policy and procedure for supervision of program staff. |
709.28 (c) 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.
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Observations
Based on two of seven records reviewed on January 29, 2020, the project failed to obtain an informed and voluntary consent form prior to the disclosure of confidential information.
Client # 1 was admitted on November 22, 2019 and was still active at the time of the inspection. The client record indicated phone conversations with the mother on December 3, 9, 2019 and January 2 and 16 2020. Also, the record indicated a family session with the mother on November 25, 2019. There was not an informed and voluntary consent form documented for the mother.
Client # 4 was admitted on November 11, 2019 and was still active at the time of the inspection. The client record indicated phone conversations with the grandmother on January 28 and 29, 2020. There was not an informed and voluntary consent form documented for the grandmother.
Client # 7 was admitted on October 8, 2019 and discharged on December 20, 2019. The client record indicated a phone conversation with a probation officer on November 20, 2019. A consent to release form was not signed by the client until December 16, 2019.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project Director shall obtain informed consent for clients 1, 4 and 7.
The Project Director shall meet with all program staff by 3/15/2020 to review the policy and procedure for obtaining informed consent from clients. All program staff shall also receive training on confidentiality laws by 3/15/20 and training shall be documented in staff training file. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on seven of seven records reviewed on January 29, 2020, the project failed to obtain a complete informed and voluntary consent to disclose form to include the specific information to be disclosed.
Client #1 was admitted on November 22, 2019 and was still active at the time of the inspection. An informed and voluntary consent to disclose form to a funding agency allowed for the release of "Relevant information".
Client #2 was admitted on January 16, 2020 and was still active at the time of the inspection. An informed and voluntary consent to disclose form to a funding agency allowed for the release of "Relevant information".
Client #3 was admitted on September 4, 2019 and was still active at the time of the inspection. An informed and voluntary consent to disclose form to a funding agency allowed for the release of "Relevant information".
Client #4 was admitted on November 11, 2019 and was still active at the time of the inspection. An informed and voluntary consent to disclose form to a funding agency allowed for the release of "Relevant information".
Client #5 was admitted on July 8, 2019 and was discharged on September 26, 2019. An informed and voluntary consent to disclose form to a funding agency allowed for the release of "Relevant information".
Client #7 was admitted on October 8, 2019 and was discharged on December 20, 2019. An informed and voluntary consent to disclose form to a funding agency allowed for the release of "Relevant information".
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Project Director shall obtain informed consent and identify the specific information to be released on the informed consent for clients 1, 2, 3, 4, 5 and 7 at the client's next appointment.
The Project Director shall meet with all program staff and review Policy and Procedure for obtaining informed consent from client by 3/15/20.
The Director of Quality Management shall oversee completion of weekly chart reviews to confirm that all required documentation is in program charts. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on review of seven of seven client records reviewed on January 29, 2020, the project failed to include documentation of the clients being notified that the project may not discriminate in the provision of services on the basis of ethnicity, marital status, or sexual orientation.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director and the Director of Quality Management shall update the clients rights policy to include that the program may not discriminate on the basis of ethnicity, marital status, or sexual orientation.
The Project Director shall meet with all program staff to review client rights by 3/15/2020.
The administrative support staff shall meet with each client in the program to review client rights by 3/15/2020. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on review of seven of seven client records reviewed on January 29, 2020, the project failed to include documentation to the client of the reasons for removing sections from their record shall be documented in the record.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director and Director of Quality Management shall modify the client rights statement to indicate reasons for removing sections from their record.
The Project Director shall meet with program staff to review the modified client rights statement by 3/15/2020.
The Administrative Support staff shall review the modified client rights statement with each client's next visit to the program.
The Director of Quality Management shall oversee weekly chart reviews to confirm that the modified client rights statement is signed by client and in the medical record. This shall occur on an ongoing basis. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
Based on a review of the project ' s policy and procedure manual on January 29, 2020, the facility failed to provide a written policy and procedures regarding medication control in the use of Buprenorphine.
These findings were reviewed with project staff during the licensing inspection.
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Plan of Correction
The Facility Director and the Director of Quality Management shall develop a policy and procedure regarding the use of Buprenorphine immediately.
The Project Director shall meet with all program staff to review the policy and procedure regarding the use of buprenorphine by 2/24/2020.
The program is not currently using bruprenorphine and has not used this in the past. |
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 project ' s policy and procedure manual on January 29, 2020, the project failed to provide procedures for responding to a physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director and the Director of Quality Management shall develop a policy and procedure for responding to a physical or sexual assault by a staff or a client.
The Project Director shall meet with all program staff to review the policy and procedure for responding to a physical or sexual assault by a staff or client. |
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 project ' s policy and procedure manual on January 29, 2020 the project failed to develop and implement procedures in responding to selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director and Director of Quality Management shall develop a policy and procedure regarding responding to selling or use of illicit drugs on the premises.
The Project Director shall meet with all program staff to review the policy and procedure regarding responding to selling or use of illicit drugs on the premises. |
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 project ' s policy and procedure manual on January 29, 2020, the project failed to develop and implement procedures in 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.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director and the Director of Quality Management shall modify the policy regarding the reporting of unusual incidents to include procedures on how to respond to death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment, or when known by the facility, for ambulatory services by 4/1/2020.
The Project Director shall meet with staff to review the modified policy and provide training on the modified procedure by 4/1/2020 |
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 project ' s policy and procedure manual on January 29, 2020, the project failed to develop and implement procedures in 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.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director and the Director of Quality Management shall modify the Reporting of unusual incidents policy to include procedures on responding to significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than one day.
The Project Director shall meet with staff to review procedure and provide training on the modified Reporting of Unusual incidents policy by 4/1/2020 |
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 project ' s policy and procedure manual on January 29, 2020, the project failed to develop and implement procedures in responding to theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director and Director of Quality Management shall modify the Reporting of Unusual Incidents policy to include procedures regarding responding to theft, burglary, break-in or similar incident at the facility by 4/1/20
The Project Director shall meet with staff to review policy and provide training on how to manage and address reporting of unusual incidents by 4/1/2020. |
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 project ' s policy and procedure manual on January 29, 2020, the project failed to develop and implement procedures in responding to event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director and the Director of Quality Management shall modify the Reporting of Unusual Incidents Policy to include procedures related to responding to an event at the facility requiring the presence of police, fire or ambulance personnel by 4/1/2020.
The Project Director shall meet with staff to review the procedures and provide training on the policy and procedures of reporting unusual incidents by 4/1/2020 |
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 project ' s policy and procedure manual on January 29, 2020, the project failed to develop and implement procedures in responding to fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director and the Director of Quality Management shall modify the Reporting of Unusual Incidents policy to include procedures related to responding to fire or structural damage to the facility by 4/1/2020.
The Project Director shall meet with all program staff to review policy and provide training on how to implement Reporting of Unusual Incidents policy and procedure by 4/1/2020. |
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 project ' s policy and procedure manual on January 29, 2020, the project failed to develop and implement procedures in responding to an outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility Director and the Director of Quality Management shall modify the Reporting of Unusual Incidents Policy to include procedures related to responding to an outbreak of a contagious disease requiring Centers for Disease Control notification by 4/1/2020.
The Project Director shall review the policy and provide training on hoe to implement the policy and procedures regarding the reporting of unusual incidents by 4/1/2020. |
709.91(b)(1) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on six of seven client records reviewed on January 29, 2020, the facility failed to provide documentation of intake procedures to include criteria for admission, treatment, completion and discharge.
Client # 1 was admitted on November 22, 2019 and was still active at the time of the inspection.
Client # 2 was admitted on January 16, 2020 and was still active at the time of the inspection.
Client # 3 was admitted on September 4, 2019 and was still active at the time of the inspection.
Client # 4 was admitted on November 11, 2019 and was still active at the time of the inspection.
Client # 5 was admitted on July 8, 2019 and was discharged August 27, 2019.
Client # 7 was admitted on October 8, 2019 and was discharged December 20, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Support person shall meet with each client in the program at the next visit to review criteria for admission, completion and discharge and document this in the chart.
Going forward, upon intake, the Administrative Support person shall review criteria for admission, completion and discharge with each client and document in the medical record.
The Director oF Quality Management shall oversee weekly chart reviews that confirm that all required documentation is being maintained in the medical record. This will occur on an ongoing basis. |
709.91(b)(2)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(i) Project policies.
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Observations
Based on six out of seven client records reviewed on January 29, 2020, the facility failed to provide documentation to the client of an orientation to the project to include: project policies.
Client # 1 was admitted on November 22, 2019 and was still active at the time of the inspection.
Client # 2 was admitted on January 16, 2020 and was still active at the time of the inspection.
Client # 3 was admitted on September 4, 2019 and was still active at the time of the inspection.
Client # 4 was admitted on November 11, 2019 and was still active at the time of the inspection.
Client # 5 was admitted on July 8, 2019 and was discharged August 27, 2019.
Client # 7 was admitted on October 8, 2019 and was discharged December 20, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Support person shall provide Orientation to each client at the next visit to program to include review of project policies and procedures and document such in the client medical record.
Going forward the Administrative Support staff person shall provide orientation to client upon intake to program policies and procedures and document such in the client medical record.
The Quality Management Director shall oversee weekly chart reviews to confirm that all required documentation is present in client medical records. This shall occur on an ongoing basis. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on six out of seven client records reviewed on January 29, 2020, the facility failed to provide documentation to the client of an orientation to the project to include: hours of operation.
Client # 1 was admitted on November 22, 2019 and was still active at the time of the inspection.
Client # 2 was admitted on January 16, 2020 and was still active at the time of the inspection.
Client # 3 was admitted on September 4, 2019 and was still active at the time of the inspection.
Client # 4 was admitted on November 11, 2019 and was still active at the time of the inspection.
Client # 5 was admitted on July 8, 2019 and was discharged August 27, 2019.
Client # 7 was admitted on October 8, 2019 and was discharged December 20, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Support staff shall meet with each client at the next visit to provide program orientation. Orientation shall include review of hours of operation. Such review shall be documented by Administrative Support Person in each client record.
Going forward the Orientation Process shall include review of program hours of operation and document such review in the client records.
The Director of Quality Management shall oversee chart reviews on a weekly basis that confirm that all required documentation is present in the medical record. |
709.91(b)(2)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iii) Fee schedule.
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Observations
Based on six out of seven client records reviewed on January 29, 2020, the facility failed to provide documentation to the client of an orientation to the project to include: fee schedule.
Client # 1 was admitted on November 22, 2019 and was still active at the time of the inspection.
Client # 2 was admitted on January 16, 2020 and was still active at the time of the inspection.
Client # 3 was admitted on September 4, 2019 and was still active at the time of the inspection.
Client # 4 was admitted on November 11, 2019 and was still active at the time of the inspection.
Client # 5 was admitted on July 8, 2019 and was discharged August 27, 2019.
Client # 7 was admitted on October 8, 2019 and was discharged December 20, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Support Staff shall provide orientation to each client to include review of the fee schedule for the program at each client's next visit. Documentation of such shall be included in the client record.
Going forward, upon intake, all clients shall receive orientation from the Administrative Support Staff to include review of the fee schedule of the program. Documentation of such shall be stored in the client's record.
The Director of Quality Management shall oversee weekly chart reviews that confirm all required documentation is maintained in client records. |
709.91(b)(2)(iv) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(iv) Services provided.
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Observations
Based on six out of seven client records reviewed on January 29, 2020, the facility failed to provide documentation to the client of an orientation to the project to include: services provided.
Client # 1 was admitted on November 22, 2019 and was still active at the time of the inspection.
Client # 2 was admitted on January 16, 2020 and was still active at the time of the inspection.
Client # 3 was admitted on September 4, 2019 and was still active at the time of the inspection.
Client # 4 was admitted on November 11, 2019 and was still active at the time of the inspection.
Client # 5 was admitted on July 8, 2019 and was discharged August 27, 2019.
Client # 7 was admitted on October 8, 2019 and was discharged December 20, 2019.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Administrative Support Staff shall provide orientation to include review of the services the program provides to each client at the next visit. Documentation of such shall be stored in the client record.
Going forward Administrative Support staff shall provide Orientation upon intake to include review of the services the program offers. Documentation of such shall be stored in the client record.
The Director of Quality Management shall oversee weekly chart reviews to confirm that all required documentation is maintained in the client record. |