INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 13-14, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Outside In Pathway to Recovery Outpatient Services 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 and a plan of correction is due on May 12, 2010.
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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 fire drill logs and an interview with the clinical supervisor, the facility failed to conduct unannounced fire drills at least once per month.The findings include:Fire drill logs for the months of April 2009 - March 2010 were reviewed on April 14, 2010. Unannounced fire drills are required at least once per month per regulation. The facility did not document any unannounced fire drills for the months of January 2010, December 2009 and May 2009.The fire drills conducted on 1/20/10, 12/16/09 and 5/6/09 were announced fired drills. The fire drills conducted on 3/10/10, 2/12/10 and 10/21/09 did not indicate whether or not they were announced or unannounced.An interview with the clinical supervisor took place on April 14, 2010. It was confirmed that the fire drills that took place for the months of January 2010, December 2009 and May 2009 were announced.
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Plan of Correction
Pathway to Recovery, Facility Director will review Fire Drill Regulation in regards to unannounced fire drill at least once a month with clinical supervisor at a stafff meeting on April 26, 2010. As of May, 2010, Pathway to Recovery program will conduct at least one unannounced fire drill on a monthly basis and the fire drill log will reflect compliance with regulation. The Facility Director will monitor fire log monthly for compliance. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs and an interview with the clinical supervisor, the facility failed to set off a fire alarm or smoke detector during each fire drill.The findings include:The fire drill logs were reviewed on April 14, 2010. Per regulation, the nonresidential facility shall set off a fire alarm or smoke detector during each fire drill. The facility failed to document on the fire drill logs that a smoke detector or fire alarm had been set off from December 2009 through March 2010.The clinical supervisor was interviewed on April 14, 2010. It was confirmed that a whistle was being used in place of setting off the smoke detector or fire alarm. It was also confirmed that no exception to setting off the fire alarm or smoke detector had been granted.
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Plan of Correction
Pathway to Recovery, Facility Director will review Fire Drill Regulation in regards to setting off smoke detector for all fire drills with clinical supervisor at a staff meeting on April 26, 2010. As of May, 2010, Pathway to Recovery program will set off the smoke detector for all fire drills conduct at the facility and the fire drill log will reflect compliance with regulation. The Facility Director will monitor fire log monthly for compliance. |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of client records, and an interview with the clinical supervisor, the facility failed to provide written documentation of the proposed type of support service, in the individual treatment and rehabilitation plans, in two of three client records.The findings include:Four outpatient client records were reviewed on April 13, 2010. Three of the clients reviewed were receiving services for the time period which required an individual treatment and rehabilitation plan. All three individual treatment and rehabilitation plans required the documentation of proposed type of support services. The facility did not document proposed type of support services in client records # 3 and 4.Client # 3 was admitted on May 18, 2009. The individual treatment and rehabilitation plan was completed on June 16, 2009. There was no documentation of support services in the treatment plan.Client # 4 was admitted on March 25, 2009. The individual treatment and rehabilitation plan was completed on May 13, 2009. There was no documentation of support services in the treatment plan.The clinical supervisor confirmed that some of the counselors were not documenting support services on the treatment plans, as required. It was reported that support services are identified on the client's aftercare plan.
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Plan of Correction
Pathway to Recovery Clinical Supervisor will review outcome of annual site visit and provide documentation training on April 30, 2010. The documentation training will address the proposed type of support services to be documented in the treatment plan. The clinical service will provide information to staff in regards to available support services. The clinical supervisor will monitor with monthly chart reviews. Any client after April 30, 2010 implementation date will reflect compliance with regulation. |