INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Licensure Programs. Based on the findings of the on-site inspection, Impact Counseling Service, LLC 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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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.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to document responses to all required unusual incidents. The facility's policy stated, "physical assault by patient" and did not include sexual assault or assaults committed by staff.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director will revise policy to include sexual assault and assaults committed by staff. Staff will b trained on new policy and implemented 9/28/2021. Project director will take responsibility for the implementation of the policy. |
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.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to document responses to all required unusual incidents. The facility's policy stated, "selling of drugs" and did not include use of illicit drugs.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director will rewrite policy to include the use of illicit drugs to all unusual incident reporting.
Project director will review changes with staff and implement changes that need to occur. |
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
Based on a review of the facility's policy and procedures manual, the facility failed to document responses to all required unusual incidents. The facility's policy did not include "which closes the facility for more than 1 day".
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director will revise policy to include language that facility will report unusual incidents that include closing the facility for more than one day. The projector director will review with staff and implement 9/28/2021. |
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
Based on a review of the facility's policy and procedures manual, the facility failed to document responses to all required unusual incidents. The facility's policy did not include this regulation.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Project Director will develop and implement policies for the events of unusual incidents that require presence of police, fire, and/or ambulance. This will be implemented and reviewed with staff 09/28/2021 |
709.34 (a) (7) 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:
(7) Fire or structural damage to the facility.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to document responses to all required unusual incidents. The facility's policy did not include this regulation.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director shall develop and implement policies and procedures to respond to the following unusual incidents: Fire or structural damage to the facility.
These will be reviewed and implemented 09/28/2021
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