INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 21, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Catholic Charities Diocese of Harrisburg, PA, 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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709.34 (a) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(1) Physical assault or sexual assault by staff or a client.
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Observations
Based on the review of the project ' s policy and procedures, the project failed to provide written procedures to respond to the following unusual incidents: Physical assault or sexual assault by staff or a client.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will update and revise the current policy 709.34 and reference specific procedures for this particular incident described in PA regulation 709.34 (1) by 10/1/2020. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on the review of the project ' s policy and procedures, the project failed to provide written procedures to respond to the following unusual incidents: Selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will update and revise the current policy 709.34 and reference specific procedures for this particular incident described in PA regulation 709.34 (2) by 10/1/2020. |
709.34 (a) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(3) Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
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Observations
Based on the review of the project ' s policy and procedures, the project failed to provide written procedures to respond to the following unusual incidents: Death or serious injury due to trauma, suicide, medication error or unusual circumstances while in residential treatment or, when known by facility, for ambulatory services.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will update and revise the current policy 709.34 and reference specific procedures for this particular incident described in PA regulation 709.34 (3) by 10/1/2020. |
709.34 (a) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(4) Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
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Observations
Based on the review of the project ' s policy and procedures, the project failed to provide written procedures to respond to the following unusual incidents: Significant disruption of services due to disaster such as fire, storm, flood or other occurrence which closes the facility for more than 1 day.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will update and revise the current policy 709.34 and reference specific procedures for this particular incident described in PA regulation 709.34 (4) by 10/1/2020. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on the review of the project ' s policy and procedures, the project failed to provide written procedures to respond to the following unusual incidents: Theft, burglary, break-in or similar incident at the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will update and revise the current policy 709.34 and reference specific procedures for this particular incident described in PA regulation 709.34 (5) by 10/1/2020. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the project ' s policy and procedures, the project failed to provide written procedures to respond to the following unusual incidents: Event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will update and revise the current policy 709.34 and reference specific procedures for this particular incident described in PA regulation 709.34 (6) by 10/1/2020. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on the review of the project ' s policy and procedures, the project failed to provide written procedures to respond to the following unusual incidents: Fire or structural damage to the facility.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will update and revise the current policy 709.34 and reference specific procedures for this particular incident described in PA regulation 709.34 (7) by 10/1/2020. |
709.34 (a) (8) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(8) Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
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Observations
Based on the review of the project ' s policy and procedures, the project failed to provide written procedures to respond to the following unusual incidents: Outbreak of a contagious disease requiring Centers for Disease Control (CDC) notification.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Program Director will update and revise the current policy 709.34 and reference specific procedures for this particular incident described in PA regulation 709.34 (8) by 10/1/2020. |