INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20-21, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Treatment Services was found 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:
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Plan of Correction
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705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from January 2023 - December 2023, the facility failed to document use of alternate exit routes during evacuations. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Agency will have a more intense fire drill safety for all staff and patients.
When fire drills happen monthly, the Agency will use all 4 exit doors instead of limiting the exits that can be used. Exit doors used will be based upon the safety and quickness for exit.
Staff and patients will discuss fire drill safety at each drill and the "meeting place" for safety will be reminded as well.
The process will be monitored monthly by the Executive Director when fire drills occur and we will document this more clear in our fire drill logs. |
709.92(a) 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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in five out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed during the first primary (therapist) appointment.Client #1 was admitted on April 5, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than May 10, 2023; however, there was no documentation of it being completed until June 13, 2023.Client #4 was admitted on March 21, 2023, and was discharged on May 9, 2023. A comprehensive treatment plan was due no later than April 26, 2023; however, there was no record on one being completed.Client #5 was admitted on April 10, 2023, and discharged on June 15, 2023. A comprehensive treatment plan was due no later than May 1, 2023; however, it was not completed until June 7, 2023. Client #6 was admitted on April 6, 2023, and discharged on August 10, 2023. A comprehensive treatment plan was due no later than May 8, 2023; however, it was not completed until June 18, 2023. Client #7 was admitted on April 14, 2023 and discharged on August 23, 2023. A comprehensive treatment plan was due no later than May 22, 2023; however, it was not completed until June June 22, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff will be re-trained about the importance of getting patients in on a timely manner and the comprehensive treatment plan is always completed on the first primary session with the counselor.
We will continue to monitor the primary sessions weekly on a google document to ensure promptness of sessions and front staff will continue to call the patient for a reminder call the day before their appointment.
Clinical Director will re-train staff on 1/25/24 and keep track of primary counselor appointments being booked in the Agency. |
709.92(a)(3) 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:
(3) Proposed type of support service.
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Observations
Based on a review of outpatient client records, the facility failed to document proposed type of support service on individual treatment plans in five out of six records reviewed.Client #1 was admitted on April 5, 2023, and was still active at the time of the inspection. The comprehensive treatment plan was dated June 13, 2023. Client #2 was admitted on April 18, 2023, and was still active at the time of the inspection. The comprehensive treatment plan was dated June 30, 2023. Client #3 was admitted on May 17, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was dated July 11, 2023. Client #6 was admitted on admitted on April 6, 2023, and discharged on August 10, 2023. The comprehensive treatment plan was dated June 18, 2023. Client #7 was admitted on admitted on April 4, 2023, and discharged on August 23, 2023. The comprehensive treatment plan was dated June 22, 2023. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff will be re-educated about the importance of documenting support services used while attending treatment. We know that staff are doing this, however the documentation needs to be more clear on the treatment plan.
Clinical director will hold a training in our staff meeting within the next 2 weeks to clearly go over the treatment plan objectives, actin steps, short term and long term goals. The importance of listing support services and coordination of other agencies will be addressed.
Clinical director will continue to monitor this during in house case file reviews. |
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 at a minimum of one time in first week post-discharge, as per the facility's policy, in four of four applicable client record. Client #4 was admitted on March 21, 2023, and was discharged on May 9, 2023. There was no documentation of a follow-up contact in this client record. Client #5 was admitted on April 10, 2023, and was discharged on June 15, 2023. There was no documentation of a follow-up contact in this client record. Client #6 was admitted on April 6, 2023, and was discharged on August 10, 2023. There was no documentation of a follow-up contact in this client record. Client #7 was admitted on April 14, 2023, and was discharged on August 23, 2023. There was no documentation of a follow-up contact in this client record. This is repeat citation from the January 26, 2022, and January 25, 2023 licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff will be re-trained on follow up procedure and the importance to check in with patients. We will make changes in our policy manual to make the follow up procedure a bit easier and more manageable for this to be completed. Training for all staff will be held on 1/25/24 in our staff meeting and changes will take effect for new protocol on 2/5/24.
Clinical Director and Executive director will implement changes to the policy on how our Agency will handle all successful and unsuccessful follow up calls/contact. Clinical director will monitor this in chart audits internally and randomly during supervision sessions. The follow up results will be added to the discharge list and monitored monthly. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for discharged client follow-up were submitted and approved by the Department for the January 26, 2022 and January 25, 2023, annual licensing inspections. Follow-up contact with discharged clients was found to be a ongoing deficiency during the December 20-21, 2023 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The follow up procedure for the Agency will be reflected in changes made to the policy and changes made to the inhouse procedure to follow up since it has not been consistent enough in past years.
We will have one clinical staff call all unsuccessful discharges for follow up and to try and re-engage. Another clinical staff will call all successful discharges to engage in conversation on how they are doing and offer any advice, feedback or referrals needed. This agency has a high active caseload so to delegate this to two clinical staff would be easier to manage and keep consistent. This will be documented in an excel sheet to reflect follow up was made and what the outcome was.
Executive Director and Clinical Director will make changes to the policy and come up with a better and more efficient way to check on patients and document properly. Two clinical staff will be trained and the new system will take effect on 2/5/2024. We will review this process weekly in our QA Meeting. |