INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 13, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Renewal Treatment 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of the facility's fire drill log for the months of July 2023 through July 2024, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. Overnight fire drills were documented for September 8, 2023, October 11, 2023, and November 8, 2023. An overnight fire drill was due to be completed by May 2024, but was not completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall perform a fire drill during sleeping hours at least every 6 months. Sleep hours are defined as 11PM to 6 AM. The Director of Security and Security Managers will ensure that at least one (1) fire drill is scheduled at least every 6 months between the hours of 11 PM and 6 AM. The monthly fire drills will be documented on a form titled fire drill log. The Director of Security and Security Managers shall audit the fire drill logs on a monthly basis to ensure compliance. The Director of Security and Security Managers shall be responsible for this plan of correction. This plan of correction is in place. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every thirty days in two of six applicable records.
Client #1 was admitted to inpatient on June 19, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 25, 2024. A treatment and rehabilitation plan update was due no later than July 25, 2024, but was not completed at the time of the inspection.
Client #2 was admitted to inpatient on June 20, 2024 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on June 23, 2024. A treatment and rehabilitation plan update was due no later than July 23, 2024, but was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. staff shall complete treatment reviews and updates at least every 30 days. The VP of Program Services and Clinical Supervisors provided training/instruction for the treatment staff on this deficiency and the requirement for treatment plan reviews and updates, at least every 30 days. The Clinical Supervisors shall ensure compliance by auditing the client files in the electronic health records on a regular basis (at least monthly). The VP Program Services and Clinical Supervisors shall be responsible for this plan of correction. This plan of correction is in place. |