INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on December 1, 2022 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Drug and Alcohol Rehabilitation Services Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on a review of administrative documentation, the facility failed to file a written unusual incident report with the Department within three business days following an unusual incident involving physical assault.
Four physical altercations between clients occurred between February 2022 and April 2022. These altercations were on February 9, February 20, March 12, and April 30.
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Plan of Correction
The failure to file reports related to physical altercations was a result of a misinterpretation of the established reporting requirements.
As a result of the site visit, our reporting procedures have been amended to ensure that any instances of physical aggression by a client toward another client or staff member, will be reported within three business days via the Electronic Reporting System.
Adherence to this policy will be completed by the Clinical Director and overseen by the Program Director. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of administrative documentation, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered that the facility had an unusual incident occur on March 30, 2022, which involved the presence of police onsite and the facility did not submit a written unusual incident report to the Department within the regulatory three business days.
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Plan of Correction
Any event requiring the presence of police, EMS, fire department, or other emergency services, will be reported through an Unusual Incident Report via the Electronic Reporting System.
Previously, it was believed that Unusual Incident Reports were required only when emergency services personnel transported a client from the facility due to medical or legal emergency. This correction has been communicated to all DARS, Inc. staff via internal training and will be included in new hire training, which is overseen by the Training Coordinator. |
709.53(a)(7) LICENSURE correspondence
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:
(7) Client-related correspondence.
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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 client-related correspondence in one out of six records reviewed.
Client # 4 was admitted on February 15, 2022 and left treatment on March 30, 2022. Administrative documentation showed that on March 30, 2022, the facility corresponded with the local police department and with a juvenile probation officer. The facility also attempted to contact the client's emergency contact on this same date. However, documentation was missing from this client record relating to this correspondence.
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Plan of Correction
The record of client correspondence will be reviewed within one business day of an event involving contact with the on-call clinician and emergency responders. The on-call counselor will be responsible for updating the contact log for any client whom required contacts to be made outside of clinical hours.
This record will be updated as a part of the review of the event(s) that required the notification of the on-call clinician.
This will be monitored by the Clinical Director to ensure compliance. |