INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 16, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the 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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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 seven of seven client records reviewed, the facility failed to provide a complete orientation to the project which shall include, but is not limited to, a familiarization with the hours of operation. Client # 1 was admitted on October 12, 2022 and was still active at the time of the inspection.Client # 2 was admitted on November 7, 2022 and was still active at the time of the inspection.Client # 3 was admitted on January 20, 2023 and was still active at the time of the inspection.Client # 4 was admitted on June 29, 2022 and was still active at the time of the inspection.Client # 5 was admitted on November 28, 2022 and was discharged on February 17, 2023.Client # 6 was admitted on February 21, 2022 and was discharged on August 16, 2022.Client # 7 was admitted on December 15, 2022 and was discharged on January 31, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Compliance Department updated the Client Intake forms in the Electronic Medical Records to include a section that reviews the hours of operations of the program with each client. This form is signed by both the client and staff person, acknowledging understanding of the information provided. Facility Director met with all clinical and intake staff to review this change in the intake and orientation process on 3/17/2023. |
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 four of seven client records reviewed, the facility failed to provide a complete orientation to the project which shall include, but is not limited to, a familiarization with the fee schedule. Client # 1 was admitted on October 12, 2022 and was still active at the time of the inspection.Client # 3 was admitted on January 20, 2023 and was still active at the time of the inspection.Client # 4 was admitted on June 29, 2022 and was still active at the time of the inspection.Client # 5 was admitted on November 28, 2022 and was discharged on February 17, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director and Compliance Department updated the Client Intake forms in the Electronic Medical Records to include a section that reviews the fee schedule for services provided by the program. This form is signed by both the client and staff person, acknowledging understanding of the information provided. Facility Director met with all clinical and intake staff to review this change in the intake and orientation process on 3/17/2023. |