INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 12, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Western Pennsylvania Counseling Services LLC dba Forge Health 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) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of six personnel records, the facility failed to ensure that each staff was instructed in the use of the fire extinguishers upon employment in two records reviewed.Employee # 4 was hired as a counselor on June 24, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until September 10, 2024.Employee # 5 was hired as a counselor on August 5, 2024 and was due to be trained in the use of fire extinguishers upon employment; however, fire safety training was not documented as complete until September 9, 2024.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All new staff will have Fire Safety training within the first 7 days of hire. The Training and Development Team will include this training on the New Hire Onboarding Training Checklist and this training will auto populate in the training system during the first week of hire. The Executive Clinical Director will run a transcript of completed trainings at the conclusion of the new hire's first week to ensure completion of this and all required trainings. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from January 2024 through August 2024, the facility failed to prepare alternate exit routes as the same stairwell was used in each drill.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director and the Clinic Director will review all exit routes in building with all staff to ensure alternate routes are utilized. Exit routes and rallying areas will be reviewed (and walked) monthly during all staff meeting. Monthly fire drills will be reviewed and monitored for use of all exit routes from the suite as well as the building. Fire drills will be set up to require that alternate routes need to be utilized to ensure staff are practicing and aware of all possible evacuation routes. |
709.28 (c) (4) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the dated signature of the client in one record reviewed.Client # 2 was transferred to the Outpatient level of care at this facility on March 4, 2024 and was discharged on June 14, 2024. The record contained a consent to release information form to the funding source was dated January 31, 2024 by the witness, but did not contain the client's signature.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Clinical Director will train and review with all clinicians and office managers the process of completing the clinical service agreement and all release of information documents and ensuring the client's signature is visible at the time of intake. Charts will be audited to ensure documentation is completed properly and completely by the Executive Clinical Director or the Clinic Director on a monthly basis. |
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
Client # 5 was transferred to this facility on January 5, 2024, from the same level of care in a different licensed facility in this project and was discharged on June 14, 2024. The individual treatment and rehabilitation plan was completed on December 21, 2023, and the treatment plan update was due no later than February 21, 2024; however, the treatment plan update was not completed until March 21, 2024. The next treatment plan update was due to be completed by May 21, 2024; however, the update was not completed until June 13, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director will review proper treatment plan procedures with clinical Team during weekly clinical rounds. Executive clinical director will also review in individual supervision. Executive Clinical Director will randomly pull chart to audit and ensure Outpatient treatment Plans are being updated every 60 days. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information within seven days of admission and every 90 days thereafter, per facility policy, in all seven records reviewed. These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
Executive Clinical Director will ensure that case consultation of clients within 7 days of intakes and then again, every 90 days thereafter. Case consultation notes will be reflected in EMR of each client. The Executive Clinical Director will review case consultation documentation with all staff to ensure understanding. Charts will be audited on a monthly basis by the Executive Clinical Director or the clinic Director. A calendar system of clients will be put into place by the Executive Clinical Director in order to accurately track and monitor competition of case consultations. |
709.93(a)(11) 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information, in one of three applicable records reviewed. Client # 6 was admitted on March 19, 2024 and was discharged on April 12, 2024. The record did not contain documentation of follow-up information.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Clinical Director will review and revise existing Follow-Up policy to add specifics of staff responsibility. Staff will be trained to follow up 30-, 60- and 90-days post discharge from substance use, co-occurring or intensive outpatient level of treatment. The Executive Clinical Director will train all staff to comply with updated Follow-Up policy. Executive Clinical Director to randomly pull chart audits to ensure policy is being followed |