INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 11-12, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, St. Joseph Institute, LLC 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to provide close supervision by a trained counselor or clinical supervisor for the first 6 months of employment.
Employee #7 was hired as a counselor assistant on November 22, 2022 and was still employed at the time of the inspection. She did not have documentation of close supervision for six months.
This findings was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Clinical Supervision form was edited by the Director of Clinical Services. The wording "Case Review" was added to the form in the section for "areas to be addressed" during the 1 hour clinical supervision with the counselor assistant. They type of supervision, the competency observation, the length of the supervision and areas to be addressed are all documented on this form. This form will be completed during each 1 hour weekly supervision. The Director of Clinical Services began to use the updated form as of 11/1/2023. The Director of Clinical Services will submit weekly documentation to the CEO to review for 100% compliance for six months. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to maintain hot water not exceeding 120 degrees. Room #1 in Sycamore had hot water measured at 130 degrees.
This findings was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Environmental Services will check the water temperature daily in Room #1 of Sycamore beginning on 11/1/2023. At any point if the temperature exceeds 120 degrees, the Director of Environmental Services will decrease the hot water temperature. This will be monitored daily through 12/31/2023 and then monitored monthly by the Director of Environmental Services and a log of all readings will be completed. At any time if the water temperature needs to be adjusted, the entire Sycamore building will be checked. If this issue continuously occurs an outside vendor/plumber will be contacted. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of inpatient non-hospital client records, the facility failed to notify the emergency contact for a client that discharged AMA for one out of one applicable files.
Client #22 was admitted on September 20, 2023 and discharged on September 25, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Clinical Services will educate/train staff on the requirement to notify the emergency contact for any ASA discharge at the November Clinical Staff meeting on 11/1/23 The Clinical staff will sign attestation forms acknowledging the education/training they received on this issue. The Director of Clinical Services will monitor the completion of this notification for 100% compliance through monthly chart audits of all ASA discharges. Results of the audits will be discussed during leadership meetings, CoW meetings, Individual clinical supervisions, and Clinical team meetings. |
709.28 (c) 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.
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Observations
Based on a review of detox client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of fourteen records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #27 was admitted on October 5, 2023 and was still active at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Admissions will educate/train staff on the proper completion of consents by 11/1/2023. The staff will complete attestation forms for this education/training. An audit will be completed for all current patients by 11/1/2023 for accurate completion of consents. Going forward, all newly signed consents will be audited by the Director of Admissions for 100% compliance through 12/31/2023. Issues with be corrected in real time and results will be reported during daily leadership meetings. After 12/31/2023, the Admissions Director will track completion with monthly audits. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures which included the response to an event at the facility involving selling or use of illicit drugs on the premises.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director of Compliance will update the policy by 11/20/2023 to reflect how the facility will respond to an event involving selling or use of illicit drugs on the premises. The updated policy will be sent to the Corporate Risk Manager and the Corporate Director of Quality and Compliance for approval by 11/30/2023. Once the updated policy is approved, it will be reviewed with Management staff. |
709.34 (a) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(5) Theft, burglary, break-in or similar incident at the facility.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures which included the response to an event at the facility involving theft, burglary, break-in or similar incident.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance will update the policy by 11/20/2023 to reflect how the facility will respond to an incident of theft, burglary, break-in or similar incident on the premises. The updated policy will be sent to the Corporate Risk Manager and the Corporate Director of Quality and Compliance for approval by 11/30/2023. Once the updated policy is approved, it will be reviewed with Management staff. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures which included the response to an event at the facility involving fire or structural damage.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance will update the policy by 11/20/2023 to reflect how the facility will respond to an event involving fire or structural damage at the premises. The updated policy will be sent to the Corporate Risk Manager and the Corporate Director of Quality and Compliance for approval by 11/30/2023. Once the updated policy is approved, it will be reviewed with Management staff. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures which included implementation of a timely and appropriate corrective action plan, when indicated.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Compliance will update the policy by 11/20/2023 to reflect how the facility will implement a timely and appropriate corrective action plan. The updated policy will be sent to the Corporate Risk Manager and the Corporate Director of Quality and Compliance for approval by 11/30/2023. Once the updated policy is approved, it will be reviewed with Management staff. |
709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures which included ongoing monitoring of the corrective action plan.
This finding was reviewed with facility staff during the licensing process
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Plan of Correction
The Director of Compliance will update the policy by 11/20/2023 to reflect how the facility will monitor the corrective action plan. The updated policy will be sent to the Corporate Risk Manager and the Corporate Director of Quality and Compliance for approval by 11/30/2023. Once the updated policy is approved, it will be reviewed with Management staff |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of inpatient rehabilitation client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in one out of one applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 7 days following discharge.
Client #7 was admitted on August 17, 2023 and discharged on September 15, 2023. A follow up was due no later than September 22, 2023; however, it was not completed until September 26, 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 10/31/2023, The Alumni Coordinator will be trained by the Director of Compliance on the requirement to follow-up within the facility's policy of 7 days of discharge. The Director of Business Development will monitor for 100% compliance by monthly chart audits. |