INITIAL COMMENTS
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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, Treatment Trends Inc. Half-way Home of The Lehigh Valley 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drills from January 2021 until November 2021, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
To address this deficiency, the Program Director will review "sleeping hour" drill times with the House Manager. The House Manager will ensure that a sleeping hours fire drill occurs in congruence with the fire-drill schedule; current practice is that a sleeping hours drill is scheduled once per quarter. The House Manager will bring all completed fire activity logs to the Program Director for review, and then submit the report(s) to the Quality Assurance Coordinator for final review/file. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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:
(8) Case consultation notes.
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Observations
Based on a review of the facility ' s policy and procedure manual and seven patient records, the facility failed to complete and document at least one case consultation in all three applicable client records. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
To address this deficiency, the Counselor/Counselor Assistant will complete case consultations as directed in the policy and procedure (at least once every 90 days, and once per treatment stay, prior to discharge). Case Consultations are reviewed weekly in the staff meeting and are to be transcribed into the EMR within 24 hours. During supervision, the Clinical Supervisor will review Case Consultation Status with each Counselor/Counselor Assistant for their respective caseloads. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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 the facility ' s policy and procedure manual and seven patient records, the facility failed to complete and document follow up information in all three applicable client records reviewed. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
To address this citation, the Program Director will appoint the Clinical Associate as the staff member responsible for conducting follow-up calls. The Clinical Associate will attempt to contact the discharged client within 7 days of discharge and note the outcome in the EMR. Follow up calls will be reviewed during monthly by the Program Director during supervision with the Clinical Associate. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that all work done by the client at the project is an integral part of his treatment and rehabilitation plan in all seven client records reviewed.These findings were discussed with facility staff during the inspection process.
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Plan of Correction
To address this citation, the Program Director and Clinical Supervisor will conduct a treatment plan training for all clinical staff members. This training will include, but is not limited to: ensuring that the client record contains the verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan. The treatment plan training will be completed by March 31, 2021 and the treatment plans will be review by the Clinical Supervisor during weekly supervision. |