INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 24, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Visualize Change, 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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705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. Additionally, the facility failed to keep the exterior of the building and the building grounds or yard free of hazards.
- There were missing floor coverings in a counseling office, back hallway, and back room, which exposed the subflooring, and posed a safety hazard.
- The lights in the counseling office were not operating.
- The counseling office had exposed electrical wires, which allowed for a possible electrical shock/hazard.
- The counseling office had missing ceiling tiles, which exposed several electrical wires, posing an electrical hazard.
- The back exterior exit had construction materials thrown on the ground, as well as broken chairs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility Director will make sure that the missing floor coverings in a counseling office, back hallway, and back room, which exposed the subflooring, will be replaced within 3 months, by 7/16/23.
The lights in the counseling office as well as exposed electrical wires and missing ceiling tiles will be fixed within 3 months, ny 7/16/23.
Construction material in the back has been removed.
Facility director will inspect the facility monthly to ensure the offices are safe and free of hazards and trash.
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705.22 (4) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it at least once every week.
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Observations
Based on a physical plant inspection, the facility failed to store all trash, garbage, and rubbish in noncombustible, covered containers that prevent insects and rodents. The counseling office had trash and ripped boxes located within the office. Additionally, there was discarded construction materials in the backyard, all of which were not stored in noncombustible, covered containers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The rippied boxes, trash, etc in this office has been removed. The facility director will ensure that all rubbish is stored in noncombustible containers.
the facility director will inspect the facility monthly to ensure the policies are being followed.
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705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed. The exit, located on right side of the facility, had an orange rope and exit sign obstructing the exit from the facility grounds.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure that no exits from the facility are obstructed at any time. The facility director will inspect the grounds of the facility monthly to ensure this is accurate. |
705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the February 2022 through February 2023 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day, and on different staffing shifts during every fire drill reviewed.
The facility's hours of operation are Monday through Friday 7:00AM - 7:00PM. All fire drills conducted, during the reviewed period, were completed on Fridays. None of the fire drills were conducted on different days of the week.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
the facility director will make sure that fire drills are performed on various days of the week and at various times during the day during hours of operation.
The facility director will check the fire drill log quarterly to ensure the fire drills are being conducted according to policy. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility's policy and procedure manual, the governing body failed to develop a written plan for the coordination of client treatment and rehabilitation services, which is to include the written procedures for the management of treatment/rehabilitation services for clients.
The facility failed to develop, within their policies, timeframes for the completion of preliminary treatment plans, comprehensive treatment plans, case consultations, discharge summaries, and follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director has developed and added timeframes for the completion of preliminary treatment plans, comprehensive treatment plans, case consultations, discharge summaries, and follow-up information to the policy. |
709.30 (6) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by clients that they have been notified of their right to submit rebuttal data or memoranda to their own records in all client records reviewed.
In every client record reviewed, the client rights acknowledgement form did not include the notification of this regulatory client right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will make sure the Client Bill of Rights is updated with the appropriate information where a client will document they have been notified in writing of their right to submit a rebuttal data or memoranda to their own records in all client records reviewed.
the facility director will review the client paperwork on a yearly basis to make sure the paperwork is up to date with all relevant information. |
709.91(b)(2)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but is not limited to, a familiarization with the following:
(ii) Hours of operation.
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Observations
Based on a review of client records, the facility failed provide client orientation to the project which is to include a familiarization with the facility's hours of operation in every client record reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director added the Hours of Operation to the Welcome Packet that is given to the clients where they can become familiar with the hours of operation on 4/5/23.
the facility director will inspect the client paperwork on a yearly basis to ensure it is up to date with the latest information. |
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 ensure that treatment and rehabilitation plans are reviewed and updated at least every sixty days in four of five applicable client records reviewed.
Client #1 was admitted on April 7, 2022 and was active at the time of inspection. A treatment plan update was completed on September 1, 2022, and the next update was due no later than November 1, 2022; however, the update was completed on March 12, 2023.
Client #2 was admitted on June 8, 2022 and was active at the time of inspection. A treatment plan update was completed on August 31, 2022, and the next update was due no later than October 31, 2022; however, the update was completed on March 12, 2023.
Client #3 was admitted on September 2, 2022 and was active at the time of inspection. A treatment plan update was completed on January 19, 2023, and the next update was due no later than March 20, 2022; however, the update was completed on March 21, 2023.
Client #5 was admitted on July 11, 2022 and was discharged on February 1, 2023. The comprehensive treatment plan was completed on August 8, 2022, and the first update was due no later than October 8, 2022; however, the update was not completed prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility director will ensure that training is given once a year, to begin on 5/1/23 to all staff that treatment plans must be updated no later than 60 days from the previous treatment plan. The facility director will periodically review charts for compliance with treatment plan guidelines. |