INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 15, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Pyramid Harrisburg Outpatient 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 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the January 9, 2023, through April 1, 2024, fire drill logs the facility failed to set off the fire alarm or smoke detector during each fire drill.
The facility reported on each of the sixteen fire drills completed that a verbal command was executed in lieu of sounding the alarm or smoke detector.
The facility does not currently have an exemption waiver in place for this regulator requirement.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has encountered limitations and barriers that are preventing this location from fulfilling this regulation as it is intended. The facility is located in close proximity to other businesses and close to neighboring houses. Setting off an alarm monthly during different shifts presents many disruptions for these neighboring businesses and neighboring community housing. Therefore the program has submitted an exemption on 5/22/24. The facility has taken steps to explore various ways to meet the intent of this regulation all while mitigating the disruptions this has caused. We have been able to meet the intent of this regulation through the use of verbal command notifications that a drill is taking place. Should the exemption not be granted, the program will manually set off the fire alarms to simulate monthly fire drills. |
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 a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within fourteen days following the intake session.
Client #3 was admitted on March 6, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than March 20, 2024; however, it was not completed until April 10, 2024.
Client #4 was admitted on January 30, 2024, and discharged on March 18, 2024. A comprehensive treatment plan was due no later than February 14, 2024; however, it was not completed until February 23, 2024.
Client #6 was admitted on November 29, 2023 and discharged on January 26 2024. A comprehensive treatment plan was due no later than December 12, 2023; however, it was not completed until December 22, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
In order to abide by DDAP regulations and the agency policy, as of 6/1/2024 the clinical supervisor will complete monthly chart audits for the duration of the calendar year with special attention paid to the completion of comprehensive treatment plans within the 14 day established timeframe. Clinical supervisor will randomly choose 2 active charts on a monthly basis during regularly scheduled group supervisions to identify clients that are nearly due for comprehensive treatment plans to ensure these documents are complete within established timelines. Clinicians will participate in a mandatory retraining on documentation deadlines in a group supervision where documentation expectations are reviewed with staff. |