INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 20, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Perry Human Services, Inc. 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 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher in the back of the building near the staff break area and in the file room has not been inspection since June 2022.These findings was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director had the fire extinguishers taken to Kint Fire Protection on January 5, 2024. We create a checklist and log for each fire extinguisher to ensure this will not happen again. |
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 fire drill logs from March 2023 - November 2023, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the months of April and May 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director will keep track of each fire drill by entering the date, time, and length into a log. This log will be updated monthly, and the director will enter future fire drills in a personal calendar to ensure he does not forget to run a drill. This will begin by the end of January 2024. |
709.92(a) 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:
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Observations
Based on a review of the client records and the facility's policy that states master treatment plans are to be created within 30 days of being admitted, the facility failed to complete and document master treatment plans in four of the six client records reviewed. Client #1 was admitted on March 31, 2023 and was still active at the time of the inspection. The client record failed to contain a master treatment plan due no later than by May 1, 2023. Client #2 was admitted on June 23, 2023 and was still active at the time of the inspection. The client record failed to contain a master treatment plan due no later than July 23, 2023. Client #3 was admitted on April 17, 2023 and was still active at the time of the inspection. The client record failed to contain a master treatment plan due no later than May 17, 2023. Client #4 was admitted on April 4, 2023 and was still discharged on October 16, 2023. The client record failed to contain a master treatment plan due no later than May 4, 2023. These findings were discussed with facility staff during the inspection.
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Plan of Correction
The director will develop an audit checklist that will begin implementation on 1/2/24. The checklist will include releases of information, treatment plan due dates (Initial, Master, and Update), assessments, and other documentation entered into their chart. The Director will monitor the checklist.
The director will discuss the outcome of the audit on 1/2/24 and will develop a plan to maintain accurate charts. |
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 two out of six records reviewed.Client #2 was admitted on June 23, 2023 and was still active at the time of the inspection. A treatment plan update was completed on August 21, 2023 and the next update was due no later than October 21, 2023; however, the next update was completed on December 6, 2023. Client #3 was admitted on April 17, 2023 and was still active at the time of the inspection. A treatment plan update was completed on August 14, 2023 and the next update was due no later than October 14, 2023; however, the next update was completed on December 4, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director will develop an audit checklist that will begin implementation on 1/2/2024. The checklist will include releases of information, treatment plan due dates (Initial, Master, and Update), assessments, and other documentation entered into their chart. The Director will monitor the checklist and will perform random audit inspections.
Beginning 1/2/2024, the director will have each counselor create a checklist showing when all their treatment plans are due.
The director will discuss the outcome of the audit on 1/2/2024 and will develop a plan to maintain accurate charts. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven records reviewed.Client #3 was admitted on April 17, 2023 and was still active at the time of the inspection. The treatment plan dated August 14, 2023 indicated 1 individual session monthly. The client received 0 individual sessions for the months of October and November 2023. Client #4 was admitted on April 4, 2023 and was still active at the time of the inspection. The treatment plan dated August 14, 2023 indicated 1 individual monthly and 1 group session weekly. The client only received two group sessions in November dating November 10 and November 17, 2023 and only received on group session in October dating October 20, 2023. Client #5 was admitted on March 9, 2023 and was discharge August 18, 2023. The treatment plan dated June 16, 2023 indicated two individual sessions a month. There was no documentation that the client received individual sessions between July 25, 2023 and August 18, 2023. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director will develop an audit checklist that will begin implementation on 1/2/2024. The checklist will include progress notes and treatment plans, among other documentation. The director will add an option to an existing document that will log when progress notes are completed.
The director will also follow up with the counselors during weekly clinical meetings to gauge how each counselor is doing with charts.
The director will discuss the outcome of the audit on 1/2/2024 and will develop a plan to maintain accurate charts. |
709.93(a)(9) 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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare information in one out of three applicable discharged records reviewed.Client #4 was admitted on April 4, 2023 and was still discharged on October 16, 2023. No aftercare plan was documented in the client record. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director will develop an audit checklist that will begin implementation on 1/2/2024. The checklist will include aftercare plans and other documentation. The director will add an option to an existing document to log whether aftercare plans were completed.
The director will also follow up with the counselors during weekly clinical meetings to gauge how each counselor is doing with charts.
The director will discuss the outcome of the audit on 1/2/2024 and will develop a plan to maintain accurate charts. |