INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 9, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, High Focus Centers 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:
|
Plan of Correction
|
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
|
Observations
Based on a review of the facility's February 2024 through December 2024 fire drill logs, the facility failed to conduct fire drills at different times of the day.
The facility's hours of operation are Monday through Friday from 8:30 AM through 9:00 PM. All fire drills conducted during the timeframe reviewed were completed between 1:15 PM and 7:00 PM. There were no fire drills conducted during the facility's morning hours of operation.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
In order to abide by DDAP regulation, safety officers and clinical supervisors with the support of executive director, quality manager, and director of compliance will conduct fire drills at three different times, Morning, Afternoon, and Evening to reflect all hours of operation. Identified staff listed will re-train on site within 30 days with full compliance expectations as of 2/28/2025. Quarterly audits will occur by quality manager and executive director in order to ensure consistency in accordance with the regulation. |
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.
|
Observations
Based on a review of client records, the facility failed to document the proposed type of support services on the individual treatment and rehabilitation plan in three of eight applicable client records reviewed.
Client # 2 was admitted on October 17, 2024 and was still active at the time of the inspection. The individual treatment and rehabilitation plan was completed on November 14, 2024; however, the plan did not include any proposed type of support services.
Client # 5 was admitted on July 15, 2024 and was discharged on December 4, 2024. The individual treatment and rehabilitation plan was completed on July 22, 2024; however, the plan did not include any proposed type of support services.
Client # 7 was admitted on October 8, 2024 and was discharged on December 2, 2024. The individual treatment and rehabilitation plan was completed on October 17, 2024; however, the plan did not include any proposed type of support services.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
1. Policy Review and Revision:
The facility's current policy regarding the requirement to include client supports/proposed supports.
A specific tracking system will be implemented to ensure all treatment plans are adequately including all required sections including client supports being properly identified.
2. Staff Training and Implementation:
All clinical staff responsible for treatment plan updates will receive training on the updated policy and tracking system by 2/28/25.
The training will emphasize the importance of adhering to the regulatory expectations of client supports/proposed supports being identified as part of treatment planning process and the consequences of non-compliance.
3. Implementation of a Treatment Plan Tracking System:
The facility will implement a digital or manual tracking system to monitor due dates for treatment plan updates.
The clinical supervisor will review treatment plans as part of regular scheduled supervision.
4. Quality Assurance and Compliance Monitoring:
The Executive Director or designated staff will conduct monthly audits of treatment plans to ensure compliance with the 60-day review requirement.
Any discrepancies found during audits will be addressed immediately, and corrective actions will be taken as necessary.
Audit findings will be reviewed during monthly staff meetings to ensure ongoing compliance and process improvement.
5. Responsible Staff:
The Executive Director will be responsible for ensuring that all corrective actions are implemented effectively and that staff remain compliant with the regulation.
The Compliance Officer will oversee the audit process and report findings to management.
6. Completion Date:
Full implementation of this corrective action plan will be completed by 03/15/25, with ongoing monitoring thereafter.
By taking these steps, the facility aims to prevent the recurrence of non-compliance and ensure that all treatment and rehabilitation plans are reviewed and updated within the required 60-day timeframe.
|