D&A Facility Surveys

Pennsylvania Department of Drug & Alcohol Programs
Inspection Results

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SPANISH AMERICAN CIVIC ASSOCIATION FOR EQUALITY, INC
134 LOCUST STREET
LANCASTER, PA 17602

Inspection Results Overview Definitions Surveys Additional Services Search

Survey conducted on 01/10/2024

INITIAL COMMENTS
This report is a result of an on-site licensure renewal inspection conducted on January 10, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, SPANISH AMERICAN CIVIC ASSOCIATION FOR EQUALITY, INC 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:	Plan of Correction
704.9(b) LICENSURE Performance evaluation 704.9. Supervision of counselor assistant. (b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
Observations Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to complete a written semiannual performance evaluation based upon measurable performance standards for the counselor assistant. Employee #4 was hired as a counselor assistant on November 9, 2017 and had no semiannual or annual review completed. This finding was reviewed with the facility staff during the licensing process.	Plan of Correction The facility director will complete the written, semi-annual performance evaluation for the counselor assistant by 3/1/24. The facility director will conduct employee file reviews on a monthly basis. The project director will ensure the evaluation is completed on 3/4/24.
704.10 LICENSURE Counselor Asst Promotion 704.10. Promotion of counselor assistant. (a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor. (b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year. (c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor. (d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
Observations Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the counselor assistant failed to document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year. Employee #4 did not document that he was working toward counselor status for the current calendar year. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The counselor assistant will provide an updated document to the facility director that he continues working toward counselor status by 3/1/24. The facility director will remind the counselor assistant at least once every six months regarding continued letters for working towards counselor status. The project director will ensure this letter is completed by 3/4/23.
704.11(a)(1) LICENSURE Training Needs assessments 704.11. Staff development program. (a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components: (1) An assessment of staff training needs.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of an assessment of staff training needs. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The project director will develop policy and procedure regarding a comprehensive staff development program indicating who is responsible and the time frames for completion of an assessment of staff training needs by 3/1/24. The project director will update this policy on a yearly basis. Project director is responsible for this action being implemented.
704.11(a)(2) LICENSURE Overall Training plan 704.11. Staff development program. (a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components: (2) An overall plan for addressing these needs.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of an overall plan for addressing these needs. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The project director will develop policy and procedure regarding a comprehensive staff development program indicating who is responsible and the time frames for completion of an assessment of staff training needs by 3/1/24. The project director will update this policy on a yearly basis. Project director is responsible for this action being implemented.
704.11(a)(3) LICENSURE Training Feedback 704.11. Staff development program. (a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components: (3) A mechanism to collect feedback on completed training.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of a mechanism to collect feedback on completed trainings. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The project director will develop policy and procedure regarding the comprehensive staff development program and the process of using a mechanism to collect feedback on the completed trainings by 3/1/24. The project director will update this policy on a yearly basis. Project director is responsible for this action being implemented.
704.11(a)(4) LICENSURE Evaluation of Overall Plan 704.11. Staff development program. (a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components: (4) An annual evaluation of the overall training plan.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a comprehensive staff development program indicating who is responsible and the time frames for completion of an annual evaluation of the overall training plan. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The project director will develop policies and procedures regarding the comprehensive staff development program and the process of completing the annual evaluation of the overall yearly training plan by 3/1/24. The project director will update this policy on a yearly basis. Project director is responsible for this action being implemented.
704.11(b)(1) LICENSURE Individual training plan. 704.11. Staff development program. (b) Individual training plan. (1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
Observations Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide a written individual training plan for each employee in the required time frame, appropriate to that employee's skill level in four out of four employee records reviewed. Employee #1 was hired on September 11, 2023 as a project director and was still in the position as of the date of the inspection. No plan was documented. Employee #2 was hired on October 8, 2008 and was promoted as a facility director on August 11, 2023 and was still in the position as of the date of the inspection. No plan was documented. Employee #3 was hired on May 23, 2023 as a counselor and was still in the position as of the date of the inspection. No plan was documented. Employee #4 was hired on June 28, 2021 and was promoted on November 9, 2017 as a counselor assistant and was still in the position as of the date of the inspection. No plan was documented. These findings were reviewed with the facility staff during the licensing process.	Plan of Correction The facility director will submit a written, individual training plan for Employee #3 and Employee #4 by 3/1/24. The project director will submit a written, individual training plan for employee #2 by 3/1/24. As employee #1 is the project director, he will submit a written, individual training plan for his superior to review and sign by 3/1/24. The facility director will monitor employee charts on a monthly basis. Project director will audit said charts on 3/4/24 to ensure compliance.
704.11(g)(1) LICENSURE Trng Req-Couns Asst (g) Training requirements for counselor assistants. (1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as: (i) Pharmacology. (ii) Confidentiality. (iii) Client recordkeeping. (iv) Drug and alcohol assessment. (v) Basic counseling. (vi) Treatment planning. (vii) The disease of addiction. (viii) Principles of Alcoholics Anonymous and Narcotics Anonymous. (ix) Ethics. (x) Substance abuse trends. (xi) Interaction of addiction and mental illness. (xii) Cultural awareness. (xiii) Sexual harassment. (xiv) Developmental psychology. (xv) Relapse prevention. (h) Training hours. Training hours are not cumulative from one personnel classification to another.
Observations Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to document the completion of 30 clock hours of annual training required for counselor assistants. Employee #4 was hired on June 5, 2017 and was promoted on November 14, 2017 as a counselor assistant and was still in the position as of the date of the inspection. The facility's training year that was reviewed was from January 1, 2023 through December 31, 2023. Employee # 4's record did not document any training hours. This finding was reviewed with facility staff during the licensing inspection.	Plan of Correction The facility director will meet with employee #4 by 2/1/24 to finalize a plan of action so the counselor assistant meets the required number of training hours for 2024. The facility director will audit employee charts on a monthly basis to ensure progress on training hours. The project director will ensure progress with training hours on a monthly basis.
704.12(a)(3)(i) LICENSURE NonHosp Rehab 704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios. (a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client. (3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation). (i) Projects serving adult clients shall have one FTE counselor for every eight clients.
Observations Based on the review of the Staffing Requirements Facility Summary Report, the facility failed to keep client/staff ratios at or below the regulation limit of 8/1 for projects serving adult clients shall have a one FTE counselor for every eight clients. The counselor Full Time Equivalent (FTE) is determined by dividing the total number of hours the counselor devotes to their clients by facility ' s work week. Then, in order to obtain the counselor ' s ratio, the total number of clients on the counselor ' s caseload is divided by the FTE. The FTE counselor ' s caseload calculation is as follows: 90/40 = 2.25(FTE); 24/2.25= 10.66, which equals to a client/counselor ratio of 10:1. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The facility will prioritize hiring a third counselor/counselor assistant to equalize FTEs and meet compliance with DDAP. This will occur by 3/1/24. Facility director will ensure proper client/staff ratios are at or below regulation limit on a daily basis. Project director will remain in weekly contact with facility director to ensure compliance.
705.7 (b) (5) LICENSURE Food service. 705.7. Food service. (b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall: (5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
Observations Based on a physical plant inspection on, the facility failed to ensure frozen food was at or below 0 degrees F. The facility did not have a mechanism to ensure the temperature of frozen food was at or below 0 degrees F. This finding was reviewed with facility staff during the licensing inspection process.	Plan of Correction The facility director will purchase another mechanism to ensure the temperature of frozen food is at or below 0 degrees F by 2/1/24. Facility director will create a weekly, random log to ensure mechanisms are functioning properly. Facility director is responsible for implementing process.
705.10 (c) (4) LICENSURE Fire safety. 705.10. Fire safety. (c) Fire extinguisher. The residential facility shall: (4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
Observations Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure two employees received the required training in the use of the fire extinguishers upon employment. Employee #1 was hired on September 11, 2023 for the position of Project Director and was still employed at the time of the inspection. No training was documented. Employee #3 was hired on May 23, 2023 for the position of counselor and was still employed at the time of the inspection. No training was documented. These findings were reviewed with facility staff during the licensing process.	Plan of Correction The project director will ensure employee #1 and employee #3 will have the appropriate fire extinguisher training completed and documented by 3/1/24. Facility director will audit employee files monthly to ensure continued compliance. Project director will ensure these trainings are complete by 3/4/24.
705.10 (d) (1) LICENSURE Fire safety. 705.10. Fire safety. (d) Fire drills. The residential facility shall: (1) Conduct unannounced fire drills at least once a month.
Observations Based on a review of fire drill logs from March, 2023 through December, 2023 the facility failed to conduct an unannounced fire drill at least once a month during the months of March through September. Additionally, the facility posted the fire drill schedule in an emergency notebook for all staff and clients to access. This finding was reviewed with facility staff during the licensing inspection.	Plan of Correction The facility director will ensure that an unannounced fire drill occurs monthly and is documented throughout 2024. The facility director will also ensure the emergency notebook is secure in his office. The notebook being secured will be completed by 2/1/24. The monthly fire drills (announced and unannounced) will continue to be documented throughout 2024 for inspection. Project director will check fire drills occur on monthly basis.
705.10 (d) (3) LICENSURE Fire safety. 705.10. Fire safety. (d) Fire drills. The residential facility shall: (3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
Observations Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report, the facility failed to ensure two employees received the required training to perform assigned tasks during emergencies. Employee #1 was hired on September 11, 2023 for the position of Project Director and was still employed at the time of the inspection. No training was documented. Employee #3 was hired on May 23, 2023 for the position of counselor and was still employed at the time of the inspection. No training was documented. These findings were reviewed with facility staff during the licensing process.	Plan of Correction The facility director will ensure employees #1 and #3 understand what tasks are required of them in an emergency by 3/1/24. Employees #1 and #3 will sign a document noting they understand their tasks and it will be placed in their employee files by 3/1/24. Project director will ensure this occurs by 3/4/24.
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.
Observations Based on a review of fire drill logs from March, 2023 through December, 2023 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There is no record of a sleep fire drill being completed. This finding was reviewed with facility staff during the licensing inspection.	Plan of Correction The facility director will ensure that at least one fire drill every six months through the 2024 calendar year will be completed during sleeping hours. Project director will review fire drill log monthly to ensure sleeping hour drill occurs.
709.22 (b) (3) LICENSURE Governing Body � 709.22. Governing body. (b) The duties of the governing body include, but are not limited to, the following: (3) Documenting the project ' s organizational structure.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to document the project ' s organizational structure. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The project director will include the project's organizational structure in the policies and procedure manual by 3/1/24. Project director will review procedure on a monthly basis and ensure update is implemented by 3/4/24.
709.23 LICENSURE Project Director � 709.23. Project director. Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
Observations Based upon a review of the policy and procedure manual and discussion with facility staff, the facility failed to prepare, annually update and sign a written manual delineating project policies and procedures. This finding was reviewed with facility staff during the licensing inspection.	Plan of Correction The policy and procedure manual will be completed with current updates for review on 3/1/24. This will be signed by all writers for review.
709.24 (a) (2) LICENSURE Treatment/rehabilitation management. � 709.24. Treatment/rehabilitation management. (a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to: (2) Identification of the treatment models and practices utilized by the project.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written plan identifying the treatment models and practices utilized by the project in their residential services. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a written plan of the treatment models and practices utilized by the project by 3/1/24. P&P will be reviewed monthly by project director. Project director responsible for update by 3/4/24.
709.24 (a) (3) LICENSURE Treatment/rehabilitation management. � 709.24. Treatment/rehabilitation management. (a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to: (3) Written procedures for the management of treatment/rehabilitation services for clients.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written procedures for the management of treatment/rehabilitation services for clients. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include written procedures for the management of treatment/rehabilitation services for clients by 3/1/24. P&P will be reviewed monthly by project director. Project director responsible for update by 3/4/24.
709.24 (a) (4) LICENSURE Treatment/rehabilitation management. � 709.24. Treatment/rehabilitation management. (a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to: (4) Written procedures for referral outlining cooperation with other service providers including, but not limited to, provisions for access to emergency services.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt written procedures for referral outlining cooperation with other services providers including, but not limited to, provisions for access to emergency services. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include written procedures for referrals outlining cooperation with other service providers, including, but not limited to, provisions for access to emergency services by 3/1/24. P&P will be reviewed monthly by project director. Project director responsible for update by 3/4/24.
709.26 (a) (1) LICENSURE Personnel management. � 709.26. Personnel management. (a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to: (1) Utilization of volunteers.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures for utilization of volunteers. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include written procedures for utilizing volunteers by 3/1/24. P&P will be reviewed monthly by project director. Project director responsible for update by 3/4/24.
709.26 (a) (2) LICENSURE Personnel management. � 709.26. Personnel management. (a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to: (2) Rules of conduct.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures for rules of conduct. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include written procedures for rules of conduct by 3/1/24. P&P will be reviewed monthly by project director. Project director responsible for update by 3/4/24.
709.26 (b) (3) LICENSURE Personnel management. � 709.26. Personnel management. (b) The personnel records must include, but are not limited to: (3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
Observations Based on a review of personnel records, the facility failed to ensure that personnel records included an annual written individual staff performance evaluation, copies of which shall be reviewed and signed by the employee in one out of one applicable records. Employee #4 was hired as the counselor assistant on November 14, 2017 and was still in that position at the time of the inspection. This finding was reviewed with facility staff during the licensing inspection.	Plan of Correction The facility director will provide an annual performance evaluation of employee #4 and document it in the employee's file by 3/1/24. Facility director will audit employee files monthly for compliance. Project director will ensure implementation on 3/4/24.
709.26 (c) LICENSURE Personnel management. � 709.26. Personnel management. (c) There shall be written job descriptions for project positions.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt written job descriptions for project positions. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The job descriptions of the different types of positions working on the project will be added to the policy and procedure manual by 3/1/24. Project director is responsible for this task. Project director will review P&P monthly for compliance.
709.28 (a) (1) LICENSURE Confidentiality � 709.28. Confidentiality. (a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code � 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to: (1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written procedures to address confidentiality of client identity and records. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to address the confidentiality of client's identities and records by 3/1/24. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.28 (a) (2) LICENSURE Confidentiality � 709.28. Confidentiality. (a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code � 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to: (2) Identification of project staff having access to records, and the methods by which staff gain access.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written procedures for identification of project staff having access to records, and the methods by which staff gain access. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to address the identification of project staff having access to records and the methods by which staff gain access by 3/1/24. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.28 (b) LICENSURE Confidentiality � 709.28. Confidentiality. (b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
Observations Based on a physical plant inspection, it was observed that the facility failed to secure hard copy client records within locked storage containers.The file cabinet containing discharge files located in the reception area was not locked. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The facility director will begin a process to ensure the containers holding client records remain locked. This process will be completed by 2/1/24. The facility director will create a log which will be checked on a weekly basis to ensure the container is locked. Project director will review log on a monthly basis.
709.28 (c) (3) LICENSURE Confidentiality � 709.28. Confidentiality. (c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to: (3) Purpose of disclosure.
Observations Based on a review of client records, the facility failed to obtain a completed informed and voluntary consent which included the purpose of the disclosure in one out of seven records reviewed. Client #1 was admitted on September 18, 2023 and was discharged on December 19, 2023. A consent form dated September 21, 2023 to a government agency did not list the purpose of the disclosure. This finding was reviewed with facility staff during the licensing inspection. This is a repeat citation from the March 21, 2023 licensing inspection.	Plan of Correction The facility director will lead a training on completing informed and voluntary consent forms with patients by 3/1/24. Facility director will complete a random audit of charts to ensure compliance on a monthly basis. Project director will ensure training has occurred by 3/4/24 and will review sign-in sheet for proof training has occurred.
709.30 (1) LICENSURE Client rights � 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (1) A client receiving care or treatment under section 7 of the act (71 P. S. � 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include a client receiving care or treatment under section 7 of the act (71 P.S. 1690.107), shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include procedures on client rights under section 7 of the act (71 P.S. 1690.107) by 3/1/24. Project director will complete task. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.30 (2) LICENSURE Client rights � 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include client rights, noting that the project may not discriminate in providing services based on age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap, or religion by 3/1/24. Project director will write policy. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.30 (3) LICENSURE Client rights 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a section within client rights informing them they have the right to inspect their records and that the project, facility, or clinical director may temporarily remove portions of the records before the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for eliminating sections shall be documented in the record. This section will be updated by 3/1/24. Project director will be responsible for writing policy. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.30 (4) LICENSURE Client rights � 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (4) Clients have the right to appeal a decision limiting access to their records to the director.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include clients have the right to appeal a decision limiting access to their records to the director. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a section within client rights informing them they can appeal a decision limiting access to their records to the director by 3/1/24. Project director will write policy. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.30 (5) LICENSURE Client rights � 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a section on client rights, including clients' right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records. This update will be completed by 3/1/24. Project director will write policy. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.30 (6) LICENSURE Client rights � 709.30. Client rights. The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights. (6) Clients have the right to submit rebuttal data or memoranda to their own records.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to adopt a written policy and procedures on client rights to include clients have the right to submit rebuttal data or memoranda to their own records. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a section on client rights, including clients have the right to submit rebuttal data or memoranda to their records. This update will be completed by 3/1/24. Project director will write policy. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.32 (b) LICENSURE Medication control � 709.32. Medication control. (b) Verbal orders for medication can be given only by a physician or other medical professional authorized by State and Federal law to prescribe medication and verbal orders may be received only by another physician or medical professional authorized by State and Federal law to receive verbal orders. When a verbal or telephone order is given, it has to be authenticated in writing by a physician or other medical professional authorized by State and Federal law to prescribe medication. In detoxification levels of care, written authentication shall occur no later than 24 hours from the time the order was given. Otherwise, written authentication shall occur within 3 business days from the time the order was given.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to accurately state the regulation in their manual, as their policy required physicians to provide written authentication to a verbal order within seven days. The regulation for required the written authentication to occur within 3 business days. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a section on how physicians must provide written authentication to a verbal order within three days. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.32 (c) (1) (i) - (ii) LICENSURE Medication control � 709.32. Medication control. (c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to: (1) Administration of medication, including the documentation of the administration of medication: (i) By individuals permitted to administer by Pennsylvania law. (ii) When self administered by the client.
Observations Based on the review of medication administration records, the facility failed to document the administration, or the reason a medication was not administered in six out of six applicable records. Client #1 was admitted on September 18, 2023 and was discharged on December 19, 2023. He was prescribed Olanzapine 10mg two tablets at bedtime. There was no documentation of the medication being administered or the reason not administered on September 22-24, 2023. He was prescribed fish oil 1000mg two times daily. There was no documentation of the medication being administered or the reason not administered on August 19-October 12, 2023. He was prescribed Trazadone 100mg two tablets at bedtime. There was no documentation of the medication being administered or the reason not administered on September 22-24, 2023. He was prescribed Albuterol Inhaler 90 MCG on August 8, 2023 and there was no documentation of the medication being administered or the reason not administered. Client #2 was admitted on October 2, 2023 and was discharged on November 24, 2023. He was prescribed Hydroxyzine 100mg tablet at bedtime. There was no documentation of the medication being administered or the reason not administered on October 3-8, 2023, October 10, 2023 and October 12-24, 2023. He was prescribed Aripiprazole 30mg tablet at bedtime. There was no documentation of the medication being administered or the reason not administered on October 3-8, 2023, October 10, 2023 and October 12-24, 2023. Client #3 was admitted on October 10, 2023 and was discharged on October 22, 2023. He was prescribed Melatonin 3mg at bedtime. There was no documentation of the medication being administered or the reason not administered on October 19 and 20, 2023. He was prescribed Fluoxetine 20 mg in the morning. There was no documentation of the medication being administered or the reason not administered on October 14-22, 2023. He was prescribed Prozac 20 mg in the morning. There was no documentation of the medication being administered or the reason not administered. Client #4 was admitted on December 4, 2023 and was discharged on December 14, 2023. He was prescribed Lesinopril 10 mg once daily. There was no documentation of the medication being administered or the reason not administered on December 9 or 10, 2023. He was prescribed Amlodipine Besylate 10mg once daily. There was no documentation of the medication being administered or the reason not administered on December 9 or 10, 2023. He was prescribed Topiramate 100mg once daily. There was no documentation of the medication being administered or the reason not administered on December 9 or 10, 2023. He was prescribed Gabapentin 300 mg three times daily. There was no documentation of the medication being administered or the reason not administered on December 11 and18, 2023, one dose missed; December 9 and 10, 2023 three doses missed. He was prescribed Mirtazapine 15mg once daily. There was no documentation of the medication being administered or the reason not administered on December 1-10, 2023. Client #5 was admitted on November 14, 2023 and was still active at the time of the inspection. He was prescribed Jardiance 25mg once daily. There was no documentation of the medication being administered or the reason not administered on November 29-December 18, 2023; January 1-3, 2024 and January 5 and 6, 2024. He was prescribed Metformin HCL 500 mg once daily. There was no documentation of the medication being administered or the reason not administered on January 8, 2023. He was prescribed Escitalopram 10 mg once daily. There was no documentation of the medication being administered or the reason not administered on January 8, 2023. He was prescribed Atorvastatin Calcium 40 mg once daily. There was no documentation of the medication being administered or the reason not administered on December 12-14, 2023; December 16-22, 2023; January 1-9, 2024. Client #6 was admitted on November 1, 2023 and was still active at the time of the inspection. He was prescribed Lisinopril HCTZ 12.5mg once daily. There was no documentation of the medication being administered or the reason not administered on November 11, 13, 18-20, 22, 23, 25 and 28, 2023; December 1-4, 6-11, 14, 16-20, 24, 29 and 31, 2023. He was prescribed Depakote 250mg twice daily. There was no documentation of the medication being administered or the reason not administered on January 7 and 9 both doses, January 10 am dose. He was prescribed Omeprazole 20 mg once daily. There was no documentation of the medication being administered or the reason not administered on November 3-5, 7, 11-13, 17-20, 22-23, 25, 29-30, 2023; December 1-4, 6-7, 10-11, 14, 16-17, 21, 23, 25-26, 28-29, 2023 and January 3, 2024. He was prescribed Gabapentin 800 mg three times daily. There was no documentation of the medication being administered or the reason not administered on November 3-6, 8, 10-13, 16-20, 22, 23, 25, 28, 30, 2023; December 1, 3-4, 6-8, 10-14, 16-18, 20-22, 24-26, 28-29, 31, 2023; January 2-5, 9, 2024 (all doses); November 7, 14-15, 21, 24, 26-27, 29, 2023; December 2, 5, 9, 15, 23, 27, 2023; January 1, and 6-8, 2024. There were two doses given at 6:30 on December 19, 2023. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the March 21, 2023 licensing inspection.	Plan of Correction Organization's medical staff will provide training on medication administration and documentation during the week of 2/5/24, or 2/9/24 at the latest. A sign in sheet will be provided for proof of training. Medical staff will review medication log on an at-least monthly basis and report any incident reports to DDAP immediately. Facility manager will also review medication log on at least monthly basis and review for incident reports. He will also be in contact with medical staff to review compliance.
709.32 (c) (2) LICENSURE Medication control � 709.32. Medication control. (c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to: (2) Drug storage areas including, but not limited to, the secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements.
Observations Based on a physical plant inspection, it was observed that the facility failed to secure storage of controlled substances and other abusable drugs in accordance with State and Federal regulations and program requirements. An unlocked refrigerator containing an injectable medication was in the conference room. This finding was reviewed with facility staff during the licensing inspection process.	Plan of Correction The project will acquire a lockable refrigerator by 3/1/24. This will be completed by facility director. The facility director will create a log to ensure random, weekly checks are completed to ensure device remains locked.
709.32 (c) (3) (i) - (v) LICENSURE Medication control � 709.32. Medication control. (3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to: (i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded. (ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs. (iii) Drugs requiring special conditions for storage to insure stability are properly stored. (iv) Outdated drugs are removed. (v) Copies of drug-related regulations are available in appropriate areas.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures to include the inspection of storage areas that ensure compliance with laws. The policy and procedures did not include what is to be verified through the inspection, storage of disinfectants and external use drugs, drugs requiring special conditions, removal of outdated drugs and copies of drug-related regulations availability in appropriate areas. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include inspecting storage areas that ensure compliance with laws. The policy and procedures will be updated to include what is to be verified through the inspection, storage of disinfectants and external use drugs, drugs requiring special conditions, removal of outdated drugs, and copies of drug-related regulations available in appropriate areas. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.32 (c) (4) (i) - (ii) LICENSURE Medication control � 709.32. Medication control. (4) Methods for control and accountability of drugs, including, but not limited to: (i) Who is authorized to remove drug. (ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures to include the methods for control and accountability of drugs including who is authorized to remove the drug and a system for recording drugs. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include the methods for control and accountability of drugs, including who is authorized to remove the drug and a system for recording drugs. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.32 (c) (5) LICENSURE Medication control � 709.32. Medication control. (5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures to include the security of drugs including loss, theft or misuse of drugs. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a method to ensure the security of drugs, including loss, theft, or misuse of drugs. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.32 (c) (6) LICENSURE Medication control � 709.32. Medication control. (6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures to include the medication errors and drug reactions. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a method to address medication errors and drug reactions. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.33 (a) LICENSURE Notification of termination. � 709.33. Notification of termination. (a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
Observations Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two out of two applicable client records. Client #3 was admitted on October 10, 2023 and discharged on October 22, 2023. Client #4 was admitted on December 4, 2023 and discharged on December 14, 2023. These findings were reviewed with facility staff during the licensing inspection. This is a repeat citation from the March 21, 2023 licensing inspection.	Plan of Correction The facility director will develop a process, including a form, to inform clients of involuntary termination of client treatment by 3/1/24. If a client is involuntarily terminated, the facility director will provide the client with the termination form on the same day of involuntary discharge. The form will note the reason for discharge and how client can appeal. The facility director and counselor/counselor assistant will sign the form. There will be a line for the client to sign, however, there will also be a box if the client refuses to sign. Facility director will audit charts monthly to ensure client signature and that involuntary termination form is present.
709.34 (a) (1) LICENSURE Reporting of unusual incidents � 709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (1) Physical assault or sexual assault by staff or a client.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include physical assault or sexual assault by staff or a client. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a response to unusual incidents, including physical assault or sexual assault by staff or a client. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.34 (a) (2) LICENSURE Reporting of unusual incidents � 709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (2) Selling or use of illicit drugs on the premises.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include selling or use of illicit drugs on the premises. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a response to unusual incidents, including the selling or using illicit drugs on the premises. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.34 (a) (3) LICENSURE Reporting of unusual incidents � 709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include serious injury due to trauma, suicide, medication error or unusual circumstances. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a response to unusual incidents, including serious injury due to trauma, suicide, medication error, or unusual circumstances. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.34 (a) (5) LICENSURE Reporting of unusual incidents � 709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (5) Theft, burglary, break-in or similar incident at the facility.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include theft, burglary, break-in or similar incident at the facility. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a response to unusual incidents, including theft, burglary, break-in, or similar incidents at the facility. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.34 (a) (6) LICENSURE Reporting of unusual incidents � 709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (6) Event at the facility requiring the presence of police, fire or ambulance personnel.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include event at the facility requiring the presence of policy, fire or ambulance personnel. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a response to unusual incidents, including events at the facility requiring the presence of police, fire, or ambulance personnel. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.34 (a) (8) LICENSURE Reporting of unusual incidents � 709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for responding to unusual incidents to include outbreak of a contagious disease requiring CDC notification. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a response to unusual incidents, including events at the facility outbreak of a contagious disease requiring CDC notification. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.34 (b) (2) LICENSURE Reporting of unusual incidents � 709.34. Reporting of unusual incidents. (b) Policies and procedures must include the following: (2) Prompt review and identification of the causes directly or indirectly responsible for the unusual incident.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for unusual incidents to include prompt review and identification of the causes directly or indirectly responsible for the unusual incident. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include prompt review and identification of the causes directly or indirectly responsible for the unusual incident. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.34 (b) (3) LICENSURE Reporting of unusual incidents � 709.34. Reporting of unusual incidents. (b) Policies and procedures must include the following: (3) Implementation of a timely and appropriate corrective action plan, when indicated.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for unusual incidents to include implementation of a timely and appropriate corrective action plan. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include implementing a timely and appropriate corrective action plan. This update will be completed by 3/1/24 by project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.34 (b) (4) LICENSURE Reporting of unusual incidents � 709.34. Reporting of unusual incidents. (b) Policies and procedures must include the following: (4) Ongoing monitoring of the corrective action plan.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for unusual incidents to include ongoing monitoring of the corrective action plan. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include ongoing monitoring of the corrective action plan. This update will be completed by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.34 (b) (5) LICENSURE Reporting of unusual incidents � 709.34. Reporting of unusual incidents. (b) Policies and procedures must include the following: (5) Reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policy and procedures for unusual incidents to include reporting mechanism to ensure that reporting of an unusual incident to an entity is in compliance with State and Federal confidentiality laws. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a reporting mechanism to ensure that reporting an unusual incident to an entity complies with State and Federal confidentiality laws. This update will be completed by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.51(a)(1) LICENSURE Criteria for Admission 709.51. Intake and admission. (a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to: (1) Criteria for admission.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to document a written plan for providing for intake and admission which includes criteria for admission. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a process for intake and admission with criteria for admission. This update will be completed by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.51(a)(2) LICENSURE Treatment Methodology 709.51. Intake and admission. (a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to: (2) Treatment methodology.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to document a written plan for providing for intake and admission which includes treatment methodology. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a process for intake and admission, including treatment methodology. This update will be completed by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.51(a)(3) LICENSURE Tx Completion Requirements 709.51. Intake and admission. (a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to: (3) Requirements for completion of treatment.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to document a written plan for providing for intake and admission which includes requirements for completion of treatment. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a process for intake and admission, including requirements for completion of treatment. This update will be completed by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria 709.51. Intake and admission. (a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to: (4) Involuntary discharge/termination criteria.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to document a written plan for providing for intake and admission which includes involuntary discharge/termination criteria. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a process for intake and admission, including criteria for involuntary discharge/termination. This update will be completed by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.51(b)(2)(iii) LICENSURE Fee Schedule 709.51. Intake and admission. (b) Intake procedures shall include documentation of: (2) Client orientation to the project which includes, but it is not limited to, a familiarization with: (iii) Fee schedule.
Observations Based upon a review of client records, the facility failed to document a complete client orientation to the project which includes a familiarization with the fee schedule in seven out of seven records. This finding was reviewed with facility staff during the licensing inspection process. This is a repeat citation from the March 21, 2023 licensing inspection.	Plan of Correction The facility director will add the fee schedule to the client handbook. This process will be completed by 2/1/24. The facility director will audit client charts monthly to ensure the fee schedule is added to the handbook and present.
709.52(b) LICENSURE TX Plan update 709.52. Treatment and rehabilitation services. (b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
Observations Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of five applicable records reviewed. Client #6 was admitted on November 1, 2023 and was still active at the time of the inspection. A treatment plan update was completed on December 7, 2023 and the next update was due no later than January 7, 2024; however, it was not completed until January 9, 2024. Client #7 was admitted on November 1, 2023 and was still active at the time of the inspection. A treatment plan update was completed on December 4, 2023 and the next update was due no later than January 4, 2024; however, none was completed at the time of the inspection. These findings were reviewed with facility staff during the licensing process.	Plan of Correction The facility director will develop a training educating project staff on treatment plan regulatory timeframes. This will be completed by 3/1/24. A sign-in sheet will be completed to serve as proof of completion. The facility director will then complete a monthly, random audit of 3 charts per counselor/counselor assistant to ensure compliance.
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.
Observations Based on a review of client records, the facility failed to provide a complete client record, which is to include a follow-up in two out of four applicable records reviewed. Client #3 was admitted on October 10, 2023 and was discharged on October 22, 2023. Client #4 was admitted on December 4, 2023 and was discharged on December 14, 2023. These findings were reviewed with facility staff during the licensing process.	Plan of Correction The facility director will develop a process regarding consistent follow-up in clients' charts. This process will be completed by 3/1/24. The facility director will audit discharged charts on a monthly basis to ensure compliance with follow-up.
709.54(a)(1) LICENSURE Purchasing food/equipment 709.54. Project management services. (a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to: (1) Purchasing of food and equipment.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include purchasing of food and equipment. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a policy on dietetic services. This procedure will be updated by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.54(a)(2) LICENSURE Receiving/storing/preserving 709.54. Project management services. (a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to: (2) Receiving, storing and preserving of food stuff.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include receiving, storing and preserving of food stuff. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a policy on dietetic services, including receiving, storing, and preserving food stuff. This procedure will be updated by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.54(a)(3) LICENSURE Proper preparation of food 709.54. Project management services. (a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to: (3) Proper preparation of food.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include proper preparation of food. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a policy on dietetic services, including proper food preparation. This procedure will be updated by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.54(a)(4) LICENSURE Safety/sanitation 709.54. Project management services. (a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to: (4) Safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include safety and sanitation, including the preparation, handling, and storage of foods; the care and cleaning of dishes, utensils and work area. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a policy on dietetic services, including safety and sanitation, including the preparation, handling, and storage of foods, the care and cleaning of dishes, utensils, and work area. This procedure will be updated by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.54(a)(5) LICENSURE Personal hygiene 709.54. Project management services. (a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to: (5) Personal hygiene for those in food preparation areas.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include personal hygiene for those in food preparation areas. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a policy on dietetic services, including personal hygiene for those in food preparation areas. This procedure will be updated by 3/1/24 by thr project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.54(a)(6) LICENSURE Special dietary needs 709.54. Project management services. (a) An inpatient nonhospital project shall have written policies and procedures for its dietetic services which include, but are not limited to: (6) Special dietary needs.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to have written policies and procedures for dietetic services which include special dietary needs. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a policy on dietetic services, including special dietary needs. This procedure will be updated by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.54(b) LICENSURE Aftercare policy 709.54. Project management services. (b) The project shall develop a written client aftercare policy.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written client aftercare policy. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a written client aftercare policy. This procedure will be updated by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.54(c) LICENSURE Follow-up policy 709.54. Project management services. (c) The project shall develop a written client follow-up policy.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written client follow-up policy. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include a written follow-up policy. This procedure will be updated by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.54(d)(1) LICENSURE Outreach Identifying Persons 709.54. Project management services. (d) The project shall develop a written plan providing for outreach services which includes, but is not limited to: (1) Identifying persons in need of project services.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written plan providing for outreach service to include identifying persons in need of project services. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include outreach services, including identifying persons needing project services. This procedure will be updated by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.54(d)(2) LICENSURE Alerting Persons - Outreach 709.54. Project management services. (d) The project shall develop a written plan providing for outreach services which includes, but is not limited to: (2) Alerting persons and their families to the availability of project services.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written plan providing for outreach service to include alerting persons and their families to the availability of project services. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include outreach services, including alerting persons and their families to the availability of project services. This procedure will be updated by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.
709.54(d)(3) LICENSURE Encouraging Persons - Outreach 709.54. Project management services. (d) The project shall develop a written plan providing for outreach services which includes, but is not limited to: (3) Encouraging persons to utilize the service delivery system.
Observations Based on a review of the facility ' s policy and procedures manual, the facility failed to develop a written plan providing for outreach service to include encouraging persons to utilize the service delivery system. This finding was reviewed with facility staff during the licensing process.	Plan of Correction The policy and procedure manual will be updated to include outreach services, encouraging persons to utilize the service delivery system. This procedure will be updated by 3/1/24 by the project director. P&P will be reviewed monthly by the project director. The project director is responsible for updating by 3/4/24.