INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 31, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Ascend Clinical Services 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential 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, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as a group rooms 201, 202 and 203 had a window in the door without covering.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 02/05/2024, program staff installed window coverings on windows for counseling rooms 201, 202, and 203. The Facility Director will conduct quarterly inspections to monitor all counseling areas and will ensure privacy so that counseling sessions cannot be seen or heard. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed as a chair was observed in front of the exit in the kitchen.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Upon identification of the obstruction, staff immediately removed the chair from its position in front of the fire exit. To ensure compliance with 705.10(a)(1)(i), A documented staff training will be provided by 02/23/2024 to all facility staff emphasizing the need to ensure all fire exits remain unobstructed. The Compliance Officer will conduct quarterly inspections of the physical plant to ensure all fire exits remain unobstructed. |
709.63(a)(8) LICENSURE Follow-up Information
709.63. 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) 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 information in three out of four applicable records reviewed.
Client #5 was admitted on August 19, 2023, and was discharged August 26, 2023.
Client #6 was admitted December 11, 2023 and was discharged on December 16, 2023.
Client #7 was admitted on October 31, 2023 and was discharged on November 4, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 02/13/2024, documented follow-up calls will be made to clients 5, 6 and 7.
A training will be provided to clinical staff by 02/23/2024 regarding the need to maintain complete client records that include follow-up information.
To ensure ongoing compliance with 709.63(a)(8), the Compliance Officer will conduct monthly chart reviews to monitor compliance with internal policies and regulatory standards related to documentation of follow-up information. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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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 aftercare information in one out of one applicable discharged record reviewed.
Client #12 was admitted on August 5, 2023 and was discharged on September 1, 2023
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A training will be provided to clinical staff by 02/23/2024 regarding the need to maintain complete client records that include comprehensive, individualized aftercare information.
To ensure ongoing compliance with 709.53(a)(0), the Compliance Officer will conduct monthly chart reviews to monitor compliance with internal policies and regulatory standards related to documentation of aftercare information. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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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 a discharge summary in three out of three records reviewed.
Client #12 was admitted on August 5, 2023, and was discharged on September 1, 2023
Client #13 was admitted on May 6, 2023, and was discharged on June 4, 2023
Client #14 was admitted on October 28, 2023, and was discharged on November 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 02/13/2024, discharge summaries will be added to the records for clients 12, 13, and 14.
A training will be provided to clinical staff by 02/23/2024 regarding the need to maintain complete client records that include discharge summaries.
To ensure ongoing compliance with 709.53(a)(10), the Compliance Officer will conduct monthly chart reviews to monitor compliance with internal policies and regulatory standards related to documentation of discharge summaries. |
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 client records, the facility failed to provide a complete client record, which is to include follow up information in three out of three applicable records reviewed.
Client #12 was admitted on August 5, 2023, and was discharged on September 1, 2023
Client #13 was admitted on May 6, 2023, and was discharged on June 4, 2023
Client #14 was admitted on October 28, 2023, and was discharged on November 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
By 02/13/2024, documented follow-up calls will be made to clients 12,13,and 14.
A training will be provided to clinical staff by 02/23/2024 regarding the need to maintain complete client records that include follow-up information.
To ensure ongoing compliance with 709353(a)(11), the Compliance Officer will conduct monthly chart reviews to monitor compliance with internal policies and regulatory standards related to documentation of follow-up information. |