INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 10, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Tradition House 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) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of August 2021 through July 2022 fire drill logs, the facility failed to document which exit route was used during the August 2021 through February 2022, and April 2022 through July 2022 fire drills.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Maintenance team, whom conduct fire drills, were retrained on fire drill regulations and proper documentation on 8/25/22. Executive Director and risk leader will monitor completed fire drills forms monthly to review for accuracy. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of August 2021 through July 2022 fire drill logs, the facility failed to set off a fire alarm or smoke detector during the March 2022 through June 2022 drills.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The maintenance team will ensure that the fire alarm or smoke detector is set off for each monthly drill. Staff was retrained on fire drill prcodures on 8/25/22. Executive Director and risk leader will monitor monthly drills for accuracy and compliance. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide counseling services according to the client's individual treatment plan in seven out of seven records reviewed.
Client #1 was admitted on June 1, 2022 and was still active at the time of the inspection. A comprehensive treatment plan dated June 2, 2022 indicated group sessions weekly and individual sessions bi-weekly. The client did not have any group sessions from June 22 - July 6, 2022.
Client #2 was admitted on May 19, 2022 and was still active at the time of the inspection. The June 20, 2022 treatment plan indicated group sessions five times a week and individual sessions weekly. The client did not receive individual sessions between July 1 - 14, and July 16-24, 2022. In addition, the client did not receive group sessions between June 23 - July 11, 2022.
Client #3 was admitted on May 19, 2022 and was still active at the time of the inspection. The June 20, 2022 treatment plan indicated bi-weekly individual sessions and weekly group sessions. The client did not have any group sessions from June 28 - July 11, 2022.
Client #4 was admitted on December 8, 2021 and discharged on February 28, 2022. The January 6, 2022 and February 1, 2022 treatment plans indicated weekly group sessions and bi-weekly individual sessions. The client did not receive any group sessions from January 29 - February 7, 2022.
Client #5 was admitted on March 17, 2022 and discharged on May 18, 2022. The April 21, 2022 indicated daily group and weekly individual sessions. The client did not receive any individual sessions from March 29 - April 13 and April 30 - May 11, 2022.
Client #6 was admitted on January 24, 2022 and discharged on March 7, 2022. The January 26, 2022 treatment plan indicated group sessions weekly and individual sessions bi-weekly. The client did not receive any group sessions from January 29 - February 7, 2022.
Client #7 was admitted on March 15, 2022 and discharged on May 4, 2022. The March 18, 2022 treatment plan indicated group five times per week and individual sessions weekly. During the week of March 27 - April 2, 2022, the client only received four group sessions. In addition, the week of April 3-9, 2022, the client received two group sessions. For individual sessions, the client did not receive counseling from March 31 - April 24, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor reviewed intake process and timelines for treatment plans and individual counselilng sessions during treatment team on 8/23/22. Clinical Supervisor will continue to montior compliance and will addrress any ongoing issues during individual supervision. |