INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on October 26 - 27, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Stairways Behavioral Health Outpatient Drug and Alcohol Program 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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705.23 (3) LICENSURE Counseling or activity areas and office space
705.23. Counseling or activity areas and office space.
The nonresidential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection conducted on October 26, 2020, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. A session occurring in counselor room 204 could be heard in the hallway. And, the door blind of group room 109 was not shut permitting the group participants to be seen.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Group Room 109 has had window film placed on the door to allow for confidentiality of group members at all times. This was completed by the facility on 11/9/20.
Therapy offices were provided with white noise machines to be utilized during therapy sessions. Therapy offices were equipped with headsets to be in use during telehealth appointments to avoid the use of speakerphone, which created the issue in room 204 during the inspection. These steps were both completed by 11/25/20.
Program management will monitor common areas and therapy offices to ensure that these solutions are being applied consistently by staff and are effectively preventing sessions from being heard from the hallway. |
705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on October 26, 2020, the facility failed to maintain hot water temperatures at or below 120F. The women's restroom's hot water temperature was 123.8F and room 213's hot water temperature was 125.5F.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The maintenance department adjusted the temperature on the facility hot water heater on 10/29/20 to bring the hot water temperature within the required range.
The maintenance department and/or program management will monitor the temperature of the restroom hot water quarterly. |
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 a review of eleven client records on October 26 - 27, 2020, the facility failed to ensure that the client had been made aware of their rights. The Client Bill of Rights section in the facility's handbook did not inform clients that they may not be discriminated against based on creed.
Client #1 was admitted on July 13, 2020 and was still active at the time of the inspection.
Client #2 was admitted on April 29, 2020 and was still active at the time of the inspection.
Client #3 was admitted on June 5, 2020 and was still active at the time of the inspection.
Client #4 was admitted on February 28, 2020 and discharged on July 9, 2020.
Client #5 was admitted on March 17, 2020 and discharged on July 23, 2020.
Client #6 was admitted on July 16, 2020 and discharged on September 8, 2020.
Client #7 was admitted on May 3, 2019 and discharged on October 7, 2019.
Client #8 was admitted on September 23, 2019 and discharged on December 3, 2019.
Client #9 was admitted on February 27, 2020 and discharged on July 14, 2020.
Client #10 was admitted on March 16, 2020 and discharged on July 27, 2020.
Client #11 was admitted on April 25, 2019 and discharged on June 3, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The word 'creed' was added to the Client Rights document in the client handbook on the day of inspection. All new clients coming in since 10/27/20, have had the amended form utilized. Clients that had previously been enrolled in services are reviewing the amended Client Rights document and signing a new form. Those clients being served via telehealth due to the COVID 19 pandemic will review the document in a phone or video session and will be offered a copy to be mailed or emailed to them. The updated and completed form will be attached to the electronic medical record and documented within a general note. |
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 client records on October 26-27, 2020, the facility failed to document type and frequency in the individualized treatment plan. The client's treatment plan for individual sessions indicated 1-4X monthly and did not include a definitive number of sessions in client record #'s 3, 5, 6 and 7.
Client #3 was admitted on June 5, 2020 and was still active at the time of the inspection.
Client #5 was admitted on March 17, 2020 and was discharged on July 23, 2020.
Client #6 was admitted on July 16, 2020 and was discharged on September 8, 2020.
Client #7 was admitted on May 3, 2019 and was discharged on October 7, 2019.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training was provided to the clinical staff on 11/3/20 by program management regarding the specifications for type and frequency of services. Clinicians will work with clients during the treatment planning process to identify the target amount of sessions. A range of sessions will no longer be utilized. Program leadership will monitor treatment plans for the correct type and frequency of services during weekly chart audits and during staff supervision meetings. |