INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 5, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, ARS of Lancaster 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics for one staff member reviewed.Employee #9 was hired as a Counselor on August 16, 2021 and was due to have the communicable disease trainings no later than August 16, 2022. There was no documentation of the trainings at the time of the inspection.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #9 is scheduled to complete TB/STD training on 10/20/2022 and HIV/AIDS training on 11/07/2022-11/08/2022. Clinical supervisors are going to meet with all new hires within their first 90 days and specifically address training requirements. They will assist new hires that need the required trainings to schedule them to ensure that this does not reoccur. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drills from September 2021 thru September 2022 the facility failed to ensure that the fire drill record included the exit route used and whether the fire alarm or smoke detector was operative. There findings were reviewed with facility staff during the licensing process.This is a repeat citation from the annual inspection conducted on November 8, 2021.
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Plan of Correction
Fire/Emergency Drill Report was updated on 10/05/2022 to include check boxes identifying weather the fire alarm was sound and operative/no operative. A line was also added to identify which exits were used during the drill. Executive Director will ensure updated forms are utilized monthly. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drills from September 2021 thru September 2022, the facility failed to document if the facility set off a fire alarm or smoke detector during each fire drill.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the annual inspection conducted on November 8, 2021.
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Plan of Correction
Fire/Emergency Drill Report was updated on 10/05/2022 to include check boxes identifying weather the fire alarm was sound and operative/no operative. A line was also added to identify which exits were used during the drill. Executive Director will ensure updated forms are utilized monthly. |
715.23(b)(24) LICENSURE Patient records
(b) Each patient file shall include the following information:
(24) Follow-up information regarding the patient.
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Observations
Based on a review of seven patient records, the facility failed to provide a complete patient record, which is to include follow up information in one patient records reviewed. Patient #7 was admitted on July 21, 2015 and was discharged on July 11, 2022. There was not documentation of follow up information being completed in the patient record. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Intake coordinator is to follow up with all discharges including successful completion discharges. The intake coordinator will send a weekly update of completed calls to the Executive Director to ensure that the follow up calls are completed. This was addressed and placed into practice on 10/11/2022. |
715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of seven patient records, the facility failed to document an annual clinical evaluation of the patient in three applicable patient records.Patient #4 was admitted on August 2, 2016 and was still active at the time of the inspection. The most recent annual evaluation was due no later than August 30, 2022; however, it was not documented as of the date of the inspection.Patient #5 was admitted on January 11, 2018 and was still active at the time of the inspection. The most recent annual evaluation was due no later than January 20, 2022; however, it was not documented as of the date of the inspection.Patient #7 was admitted on July 21, 2015 and was discharged on July 11, 2022. The most recent annual evaluation was due no later than July 21, 2021; however, it was not documented as of the date of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisors will complete clinical training on patient annual evaluations with the primary counselors by 11/14/2022. The primary counselors will track the due dates for the clinical annuals on a spreadsheet to ensure timely completion. The clinical supervisors will spot check patient records monthly for the next 90 days to ensure that this does not reoccur. |