INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Crawford County Drug & Alcohol Executive Commission, 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) (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 one of thirteen personnel records reviewed, the facility failed to provide documentation of staff being instructed in the use of the fire extinguisher upon staff employment for employee # 5.Employee # 5 was hired as a counselor on October 11, 2021 and was still in this position at the time of the inspection. Instruction of the use of the fire extinguisher was not documented upon hire but instead it was completed on May 20, 2022.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire extinguisher training has been added directly to new employee's on-boarding packet. The training will be conducted by the Chief Fiscal Officer immediately upon the submission of their on-boarding packet and this would take place well within 7 days. We are immediately in compliance with this standard.
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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 four of eight client records reviewed, the facility failed to provide documentation of an individual treatment and rehabilitation plan being developed with the client in client record #'s 1, 2, 5, and 7.Client # 1 was admitted on January 27, 2022 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed on February 25, 2022 did not include documentation of the plan being developed with the client.Client # 2 was admitted on January 25, 2022 and was still active at the time of the inspection. The comprehensive treatment and rehabilitation plan developed on February 16, 2022 did not include documentation of the plan being developed with the client.Client # 5 was admitted on October 6, 2021 and was discharged February 18, 2022. The comprehensive treatment and rehabilitation plan developed on November 5, 2021 did not include documentation of the plan being developed with the client.Client # 7 was admitted on June 24, 2021 and was discharged November 12, 2021. The comprehensive treatment and rehabilitation plan developed on July 23, 2021 did not include documentation of the plan being developed with the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The following protocol will be used to assist in the development and review of individual treatment and rehabilitation plans with a client:
- Client will develop, review and agree upon the individual treatment and rehabilitation plan and verification will be included in a progress note by the counselor. This will be reviewed and signed off by the treatment supervisor.
- An alert will be added by the treatment supervisor to the counselor's caseload overview (dashboard) on our electronic medical record system. This will allow each counselor and supervisor to have access and view what treatment and rehabilitation plans need developed/reviewed and agreed upon with client.
- A pop-up reminder will be added by the treatment supervisor to client's scheduler in our electronic medical record system where notification of clients needing to develop/review and agree upon client's treatment and rehabilitation plan will push over when a client is checking in for appointment.
- If a treatment plan is constructed in absence of the client due to attendance issues, the following efforts will take place:
o If a client is not present to develop, review and agree upon their individual treatment and rehabilitation plan, documentation will be noted in the client's discharge summary.
Treatment supervisors will educate treatment staff on the standard and protocol during the two treatment team meetings following the licensing visit. The treatment supervisors will monitor compliance with the standard through routine and ongoing review of treatment plans and provide follow up training with staff, if needed. The facility will be in full compliance with the standard by June 30, 2022.
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