INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 1 - 3, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Arc Manor was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.10 (d) (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.
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Observations
The facility failed to conduct monthly fire drills. Fire drills records were reviewed from February 2018 to April 2019. A fire drill for March 2019 was not documented.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The required monthly fire drills policy will be reviewed in the Integration Meeting on 5/22/19 by the Chief Financial Officer who facilitates that meeting and in the Clinical Assistant Meeting on 5/28/19 by the Lead Clinical Assistant to ensure that monthly fire drills are conducted. The Safety Committee will review the monthly fire drills to ensure these are being completed following the regulations. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
The facility failed to conduct a fire drill during sleeping hours at least every six months. Fire drills records were reviewed from February 2018 to April 2019. A fire drill during sleeping hours has not been conducted since August 14, 2018.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Lead Clinical Assistant will review the policy regarding fire drills occurring during sleeping hours at the next Clinical Assistant Meeting on 5/28/19. It will be clarified with staff that a fire drill during sleeping hours must occur every 6 months and that it must be conducted after 11:30pm and before 6:45am. The Safety Committee will review the monthly fire drills to ensure that these are being completed and the regulations are being followed. |
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.
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Observations
The facility failed to provide a procedure addressing the security and release of electronic client records. Facility procedures were reviewed on May 1, 2019.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The confidentiality policy will be updated by the Executive Director to include information regarding the electronic health record (EHR) and the mechanisms in place to protect confidential information. The Executive Director will seek the Board of Directors' approval on the updated policy at the monthly Board Meeting on 5/20/19. The policy will then be distributed to the staff via email on 5/21/19. |
709.34 (a) (4) 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:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
The facility failed to develop a policy and procedure for the significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence which closes the facility for more than 1 day.
Policy and procedures were reviewed on May 1, 2019.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Executive Director will update the Unusual Incidents Policy to include significant disruption of services due to a disaster such as a fire, storm, flood, or other occurrence which closes the facility for more than 1 day and will seek Board approval at the monthly Board Meeting on 5/20/19. The updated policy will then be distributed to staff via email and reviewed in the clinical staff meeting on 5/23/19 by the Clinical Director and with clinical assistants at the Clinical Assistant meeting on 5/28/19 by the Lead Clinical Assistant. |
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.
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Observations
The facility failed to develop a policy and procedure for a theft, burglary, break-in or similar incident at the facility.
Policy and procedures were reviewed on May 1, 2019.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Executive Director will update the Unusual Incidents Policy to include theft, burglary, break-in, or similar incident at the facility and will seek Board approval at the monthly Board Meeting on 5/20/19. The updated policy will then be distributed to staff via email and reviewed in the clinical staff meeting on 5/23/19 by the Clinical Director and with clinical assistants at the Clinical Assistant meeting on 5/28/19 by the Lead Clinical Assistant. |
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.
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Observations
The facility failed to include the presence of an ambulance in the policy and procedure. Policy and procedures were reviewed on May 1, 2019.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Executive Director will update the Unusual Incidents Policy to include the presence of an ambulance and will seek Board approval at the monthly Board Meeting on 5/20/19. The updated policy will then be distributed to staff via email and reviewed in the clinical staff meeting on 5/23/19 by the Clinical Director and with clinical assistants at the Clinical Assistant meeting on 5/28/19 by the Lead Clinical Assistant. |
715.26(b) LICENSURE Security
(b) Each narcotic treatment program shall provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community. This plan shall designate a staff member to act as community liaison.
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Observations
The facility failed to provide the Department with a specific plan describing the efforts it will make to avoid disruption of the community by its patients and the actions it will take to assure responsiveness to the community.
Policy, procedure, and plans were reviewed on May 1, 2019.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
A policy for the MAT Security and Community Liaison regulation [715.26(b)] will be developed by the Executive Director, who will then seek Board approval for the policy at the monthly Board meeting on 5/20/19. The updated policy will then be distributed to staff via email on 5/21/19 and placed in the policy manual for the MAT program. |
715.28(a)(1-10) LICENSURE Unusual incidents
(a) A narcotic treatment program shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault by a patient.
(2) Inappropriate behavior by a patient causing disruption to the narcotic treatment program.
(3) Selling of drugs on the premises.
(4) Complaints of patient abuse (physical, verbal, sexual and emotional).
(5) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) Incident with potential for negative community reaction or which the facility director believes may lead to community concern.
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
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Observations
The facility failed to include the following in the unusual incident policy and procedure:
(6) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence.
(7) including an incident with potential for negative community reaction
(8) Theft, burglary, break-in or similar incident at the facility.
(9) Drug related hospitalization of a patient.
(10) Other unusual incidents the narcotic treatment program believes should be documented.
Policy and procedures were reviewed on May 1, 2019.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The Executive Director will update the Unusual Incidents Policy to include: significant disruption of services due to disaster such as fire, storm, flood or other occurrence; an incident with potential for negative community reaction; theft, burglary, break-in or similar incident at the facility; drug related hospitalization of a patient; other unusual incidents the narcotic treatment program believes should be documented, and will seek Board approval at the monthly Board Meeting on 5/20/19. The updated policy will then be distributed to staff via email and reviewed in the clinical staff meeting on 5/23/19 by the Clinical Director and with clinical assistants at the Clinical Assistant meeting on 5/28/19 by the Lead Clinical Assistant. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
The facility failed to update the treatment plan every 60 days in two of five client records reviewed on May 2 & 3, 2019.
Client record # 15 - A treatment plan was completed on January 28, 2019. A treatment plan was due by March 28, 2019, and it was completed on April 17, 2019.
Client record # 17 - A treatment plan was completed on December 27, 2018. A treatment plan was due by February 27, 2019, and it was completed on March 11, 2019.
These findings were reviewed with facility during the licensing process.
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Plan of Correction
The policy and regulation that all outpatient treatment plans must be reviewed every 60 days will be reviewed by the Clinical Director with clinical staff at their weekly clinical staff meeting on 5/16/19. The Clinical Director will then conduct monthly spot checks of active files during supervision sessions to check that outpatient treatment plans are being updated in a timely manner according to policy and regulations. The Clinical Director will also review the specific incidents related to client record #15 and #17 with the staff responsible for the treatment plans, providing supervision and training to these staff to ensure the regulation is followed. |