INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Angels Light Halfway House 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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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the administrative information, the facility failed to conduct fire drills at least once a month.
The facility was approved to begin services in August 2022. Fire drills were not documented from September 2022 to February 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Fire drills will be held a minimum of once a month. The Office Manager has agreed to take responsibility for conducting and documenting the fire drills until the time the facility became operational and fully staffed. At that time, the Office manager will be responsible for overseeing that a support staff (techs) person from all three shifts, conduct a minimum of one fire drill per month and documenting it in the fire drill log. Fire drills will be conducted at various times during the day and night. The first fire drill was conducted and documented on 3/2023 and will be a minimum of one time per month and one time every six months moving forward. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan in seven of seven client records.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has reviewed Chart responsibilities with clinical staff and shall continue to reinforce the importance of required clinical information and individualized treatment goals, such as work therapy for each of the clients.
All client charts shall include document verification of work being done as part of the treatment and rehabilitation plan, as well as the ASAM.
The Clinical Supervisor shall audit client files for accuracy and completion on a weekly basis. |