INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on march 6, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Treatment Trends Inc. - Half-Way Home of The Lehigh Valley 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) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
The facility failed to conduct an unannounced fire drill for the months of September 2018 and November 2018. Additionally, the facility failed to conduct an overnite fire drill during sleeping hours at least once every 6 months. These non-compliance items were discovered based on the review of the June 2018 through February 2019 fire drill logs.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address the citation for § 705.10. Fire safety, new procedures will be implemented to the current organizational policy. A standard shift schedule has been established, and only the program director and house manager are aware of it until the time of the drill. The program director is responsible for ensuring that the corrective plan as a whole is implemented and follow through monthly. The House Manager will inform the staff member as to the time of the drill. The lead person conducting the fire drill will also be in charge of the evacuation proceedings and responsible for all required documentation. Although the scheduled fire drills are required for the organization, it is possible that other evacuation drills may occur. The facility will be in full compliance with all standards for this policy effective immediately. |
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
The facility failed to provide treatment plan updates within the regulatory timeframe in three of six client records reviewed.Client #1 was admitted on December 10, 2018 and was active at the time of the inspection. A treatment plan update was completed on January 2, 2019 and the next update was due no later than February 2, 2019. However, the update was not completed until February 13, 2019. Client #2 was admitted on January 28, 2019 and was active at the time of the inspection. The comprehensive treatment plan was completed on January 31, 2019 and the first update was due no later than March 2, 2019. However, the update was not completed as of the date of the inspection. Client #3 was admitted on December 27, 2018 and was active at the time of the inspection. A treatment plan update was completed on February 1, 2019 and the next update was due no later than March 1, 2019. However, the update was not completed as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To address this citation, a treatment plan update would be completed every 30 days by the primary counselor assigned to the client. To ensure that the active client records discussed in the deficiency (clients 1, 2 and 3), will not be non-complaint, the counselor, clinical supervisor and/or program director will conduct chart audits once a month, ensuring that all treatment plans are recorded correctly and ascertained by the dates indicated on the treatment plan. The primary counselor will provide specific dates on the treatment plan when goals and objectives are due, ensuring that the start date and completion date enables the facility to come into full compliance of the guideline indicated on the treatment plan for the next treatment plan update. Clients discharged within the time of this inspection, and the completion of the POC will include a memorandum attached to the treatment plan, stating the reason why the treatment plan was non-complaint; it will be signed by the clinical supervisor and/or program director. The program director is responsible for make sure that the corrective plan as a whole is implemented and follow through monthly. |