INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial House, 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) (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
Based on a review of twelve fire drill records on June 8, 2021, the facility failed to conduct unannounced fire drills at least once a month.
There were no fire drill documented for the months of October 2020, November 2020 and December 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Technician Supervisor, along with over-sight by the Operations Manager, will ensure that monthly fire drills are conducted on-site and recorded in the Fire drill Log. This log will be reviewed monthly in supervision with the Technician Supervisor to ensure compliance. |
709.28 (c) (6) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records on June 8, 2021, the facility failed to document a completed informed and voluntary consent to release information form that included a date, event or condition upon which the consent would expire in four out of seven records reviewed.
Client #1 was admitted on April 15, 2021 and was still active at the time of the inspection. The informed and voluntary consent forms were dated April 15, 2021 to a medical provider and an emergency contact and did not include a date, event or condition upon which the consent would expire.
Client #3 was admitted on May 11, 2021 and was still active at the time of the inspection. The informed and voluntary consent forms were dated May 11, 2021 to an emergency contact and did not include a date, event or condition upon which the consent would expire.
Client #5 was admitted on January 20, 2021 and was discharged on March 16, 2021. The informed and voluntary consent forms were dated January 22, 2021 to a medical provider and an emergency contact and did not include a date, event or condition upon which the consent would expire.
Client #6 was admitted on January 22, 2021 and was discharged on April 20, 2021. The informed and voluntary consent forms were dated January 22, 2021 to four medical providers and did not include a date, event or condition upon which the consent would expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will ensure that client consents are properly filled out to include date parameters around release of confidential information. Specifically, start and end dates will be reflective of the length of validity of the consent that the client desires. Monthly chart audits, conducted by the Clinical Supervisor, will ensure adherence. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of seven client records on June 8, 2021, the facility failed to include documentation of a client orientation which includes familiarization to project policies in seven out of seven client records reviewed.
Client #1 was admitted on April 15, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to project policies.
Client #2 was admitted on April 27, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to project policies.
Client #3 was admitted on May 11, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to project policies.
Client #4 was admitted on May 19, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to project policies.
Client #5 was admitted on January 20, 2020 and was discharged on March 16, 2021.
There was no documentation of a client orientation which includes familiarization to project policies.
Client #6 was admitted on January 22, 2020 and was discharged on April 20, 2021.
There was no documentation of a client orientation which includes familiarization to project policies.
Client #7 was admitted on January 21, 2021 and was discharged on January 29, 2021.
There was no documentation of a client orientation which includes familiarization to project policies.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor, along with over-site by the Operations Manager, will ensure that the admissions coordinator is reviewing facility policies with clients and completing the client orientation checklist upon admission. monthly chart audits, by the Clinical Supervisor, will ensure compliance. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
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Observations
Based on a review of client records on June 8, 2021, the facility failed to include documentation of a client orientation which includes familiarization to hours of operation in seven out of seven client records reviewed.
Client #1 was admitted on April 15, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to hours of operation.
Client #2 was admitted on April 27, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to hours of operation.
Client #3 was admitted on May 11, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to hours of operation.
Client #4 was admitted on May 19, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to hours of operation.
Client #5 was admitted on January 20, 2020 and was discharged on March 16, 2021.
There was no documentation of a client orientation which includes familiarization to hours of operation.
Client #6 was admitted on January 22, 2020 and was discharged on April 20, 2021.
There was no documentation of a client orientation which includes familiarization to hours of operation.
Client #7 was admitted on January 21, 2021 and was discharged on January 29, 2021.
There was no documentation of a client orientation which includes familiarization to hours of operation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager will ensure that the client orientation checklist outlines the hours of operation and is reviewed with clients upon admission.
This form was modified and put into policy June 22, 2021. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
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Observations
Based on a review of client records on June 8, 2021, the facility failed to include documentation of a client orientation which includes familiarization to fee schedule in seven out of seven client records reviewed.
Client #1 was admitted on April 15, 2021 and was still active at the time of the inspection.
There was no include documentation of a client orientation which includes familiarization to fee schedule.
Client #2 was admitted on April 27, 2021 and was still active at the time of the inspection.
There was no include documentation of a client orientation which includes familiarization to fee schedule.
Client #3 was admitted on May 11, 2021 and was still active at the time of the inspection.
There was no include documentation of a client orientation which includes familiarization to fee schedule.
Client #4 was admitted on May 19, 2021 and was still active at the time of the inspection
There was no include documentation of a client orientation which includes familiarization to fee schedule.
Client #5 was admitted on January 20, 2020 and was discharged on March 16, 2021.
There was no include documentation of a client orientation which includes familiarization to fee schedule.
Client #6 was admitted on January 22, 2020 and was discharged on April 20, 2021.
There was no include documentation of a client orientation which includes familiarization to fee schedule.
Client #7 was admitted on January 21, 2021 and was discharged on January 29, 2021.
There was no include documentation of a client orientation which includes familiarization to fee schedule.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager will ensure that the client orientation checklist outlines the fee schedule and is reviewed with clients upon admission.
This form was modified and put into policy June 22, 2021. |
709.51(b)(2)(iv) LICENSURE Services Provided
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iv) Services provided.
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Observations
Based on a review of client records on June 8, 2021, the facility failed to include documentation of a client orientation which includes familiarization to services provided in seven out of seven client records reviewed.
Client #1 was admitted on April 15, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to services provided.
Client #2 was admitted on April 27, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to services provided.
Client #3 was admitted on May 11, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to services provided.
Client #4 was admitted on May 19, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization to services provided.
Client #5 was admitted on January 20, 2020 and was discharged on March 16, 2021.
There was no documentation of a client orientation which includes familiarization to services provided.
Client #6 was admitted on January 22, 2020 and was discharged on April 20, 2021.
There was no documentation of a client orientation which includes familiarization to services provided.
Client #7 was admitted on January 21, 2021 and was discharged on January 29, 2021.
There was no documentation of a client orientation which includes familiarization to services provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager will modify the client Orientation form to include an overview of facility services provided in treatment. The admissions coordinator will review this information with the client upon admission. Monthly chart audits, completed by the clinical Supervisor, will ensure compliance. |