INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 21, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Western Pennsylvania Counseling Services, LLC dba Forge Health 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility fire drill log for the months of July 2023 through November 2023, the facility failed to provide documentation of a fire drill being conducted the month of July 2023.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director will randomly choose a day and time each month to conduct a fire drill. Results of the fire drill will be recorded in a monthly log by Executive Clinical Director. Executive Director and Program Director will review logs during monthly leadership meetings. |
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
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in three of four applicable records.Client #2 was admitted to outpatient on September 6, 2023 still active at the time of the inspection. A treatment and rehabilitation plan was developed on September 8, 2023. A treatment and rehabilitation plan update was due no later than November 8, 2023, but was not completed until November 20, 2023.Client #6 was admitted to outpatient on August 18, 2023 and was discharged on November 3, 2023. A treatment and rehabilitation plan was developed on August 25, 2023. A treatment and rehabilitation plan update was due no later than October 25, 2023, but was not completed until November 21, 2023.Client #7 was admitted to outpatient on August 16, 2023 and was discharged on October 27, 2023. A treatment and rehabilitation plan was developed on August 23, 2023. A treatment and rehabilitation plan update was due no later than October 23, 2023, but was not completed until November 21, 2023.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92 Treatment / Rehabilitation Management. Executive Clinical Director will review proper Treatment Plan procedures with Clinical Team during weekly Clinical Rounds. Appointed Supervisors will also review in individual supervision. Program Director will randomly pull chart audits to ensure Outpatient treatment Plans are being updated every 60 days. All items listed will be completed by 01.01.2024. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in two of two records. The policy and procedure manual indicates follow-up contact must be made at fourteen days, thirty days, sixty days, ninety days, six months, nine months, and one year after discharge.Client #6 was admitted to outpatient on August 18, 2023 and was discharged on November 3, 2023. The client record contained no documentation that follow-up was completed.Client #7 was admitted to outpatient on August 16, 2023 and was discharged on October 27, 2023. The client record contained no documentation that follow-up was completed.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.93 Client Records. The Executive Clinical Director will review and revise existing Follow - Up policy to add specifics of staff responsibility and timing. The Executive Clinical Director will train all staff to comply with updated Follow -Up policy. Program Director to randomly pull chart audits to ensure policy is being followed. All items listed will be completed by 01.01.2024 |