INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 27, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clinical Outcomes Group Incorporated 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:
|
Plan of Correction
|
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
|
Observations
Based on a physical plant inspection, the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher tag. The fire extinguisher in the kitchen was last serviced in March 2020. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Fiscal Director notified landlord on 1/27/2022 that the fire extinguisher in the kitchen was not inspected since March 2020. The landlord contact the agency that takes care of the fire extinguishers and they visited the agency on 2/1/2022 to inspect the extinguisher in the kitchen.
The fiscal director will work with the agency that inspects the fire extinguishers annually to ensure that all extinguishers are up to date. This will occur annually in the month of May. |
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
Based on a review of the March 2021 through December 2021 fire drill logs, the facility failed to document whether a fire alarm or smoke detector was operative at the time of the drill. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Beginning February 1, 2022, Clinical Outcomes Group staff member will document on the fire drill log that the alarm and smoke detector were operative at the time of each monthly fire drill. The ED will follow-up each month to ensure that both information is being documented and that the alarm and detectors are working. |
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
Based on a review of the March 2021 through December 2021 fire drill logs, the facility failed to document if a fire alarm or smoke detector was set off during drills March 2021-December 2021These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
On 1/27, 2022, a letter was submitted to DDAP licensing by the Executive Director requesting an exception to pulling the fire alarm. On 2/1/2022, a letter was received from DDAP stating that an exception was not required but granted. It further stated that COGI needed to document that the alarm system is/was in working order and will be documented on the log monthly.
This was noted in the previous citation and will be monitored by the ED on a monthly basis beginning February1, 2022. |
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.
|
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 client records reviewed.Client #3 was admitted on September 1, 2021 and was still active at the time of the inspection. A treatment plan was completed on October 1, 2021 and an update was due no later than December 1, 2021; however, the next update documented was January 3, 2022.Client #4 was admitted on June 24, 2021 and was still active at the time of the inspection. A treatment plan update was completed on September 7, 2021 and the next update was due no later than November 7, 2021; however, the update documented was dated December 10, 2021.Client #5 was admitted on July 13, 2021 and was discharged on December 15, 2021. A treatment plan was completed on July 20, 201 and an update was due no later than September 20, 2021; however, the update documented was dated November 1, 2021.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Client #3 -Counselor will complete an update for client #3 by 2/20/2022 for the plan missed for December 1, 2021 and will document in the review that although the treatment plan update is being done late, it was a review of his active plan for December.
The clinical supervisor - Counselor and all clinical staff were directed on 2/4/2022 to complete the review of the treatment plan every 60 days regardless if the client is present at the time. The counselor and clinical staff were then directed to document in the treatment plan update that when the client shows for their next session an update will occur and their signature obtained. The supervisor informed the counselor and clinical staff that the next treatment plan update was due 60 days from the original treatment plan update and not when the client signed it.
The clinical supervisor will monitor charts during monthly chart audits beginning 2/10/2022.
#4 Counselor for #4 will complete a treatment plan update November 7, 2021 by 2/24/2022. The counselor will document in the update that although late, the review will cover the time missed. Counselor and all clinical staff were directed on 2/4/2022 to complete the review of the treatment plan every 60 days regardless if the client is present at the time. The counselor and clinical staff were then directed to document in the treatment plan update that when the client shows for their next session an update will occur and their signature obtained. The supervisor informed the counselor and clinical staff that the next treatment plan update was due 60 days from the original treatment plan update and not when the client signed it.
The clinical supervisor will monitor charts during monthly chart audits beginning 2/10/2022.
#5 Counselor #5 will go into the discharged client chart and document in the treatment plan update section that a plan was missed in September 2021 and a review will be completed for that time frame by 2/24/2022. Counselor and all clinical staff were directed on 2/4/2022 to complete the review of the treatment plan every 60 days regardless if the client is present at the time. The counselor and clinical staff were then directed to document in the treatment plan update that when the client shows for their next session an update will occur and their signature obtained. The supervisor informed the counselor and clinical staff that the next treatment plan update was due 60 days from the original treatment plan update and not when the client signed it.
The clinical supervisor will monitor charts during monthly chart audits beginning 2/10/2022. |