INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Clear Concepts Counseling 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) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the April 2024 through March, 2025 fire drill logs, the facility failed to document whether or not the smoke detector was operative during the October 29, 2024 and November 5, 2024 fire drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed during our agency staff meeting on May 15, 2025. The Project Director will review the proper documentation of the fire drill log pertaining to the use of a smoke detector that must be documented on the fire drill log. The Project Director will review the fire drill log monthly to ensure the log is completely and correctly documented. |
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 a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of four applicable records reviewed.
Client #1 was admitted on August 20, 2024, and was still active at the time of the inspection. A treatment plan update was completed on November 12, 2024, and the next update was due no later than January 12, 2025; however, it was completed February 4, 2025.
Client #2 was admitted on September 5, 2023, and discharged on September 17, 2024. A treatment plan update was completed on June 10, 2024, and the next update was due no later than August 10, 2024; however, it was completed on August 11, 2024.
Client #4 was admitted on June 25, 2024, and discharged on December 10, 2024. A treatment plan was completed on July 23, 2024, and the next update was due no later than September 23, 2024; however, it was completed on October 15, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Our facility will be in full compliance with this standard beginning immediately. This standard and our agency policy relative to this standard will be reviewed during our agency staff meeting on May 15, 2025. The Clinical Supervisor and Project Director met with the counselors of client records #1, 2 and 4 to ensure the treatment plan updates will be completed every 60 days as per the agency policy. To ensure completion of treatment plan updates at least every 60 days the Project Director will review charts on a weekly basis to verify completion. The Clinical Supervisor will also review the individual counselor's client records on a weekly basis to ensure compliance. |