INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 17-18, 2021 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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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling room. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The camera in the counseling room of Appalachian was removed on 12/6/2021 by Maintenance staff. All counseling room cameras have been removed and cameras will no longer be placed in counseling areas. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the October 2020 through October 2021 fire drill logs, the facility failed to document if the smoke detector or fire alarm was operative at the time of the drill during the months of August 2021, September 2021, and October 2021. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Every month a fire drill will be conducted and every building's fire alarm will be tested during the drill. Fire drills will be conducted monthly by Maintenance staff and it will be documented on the Fire Drill Report Form. The facility will be in compliance with the next fire drill conducted on or before December 31, 2021. Tracking of the drills will be completed by the Maintenance Supervisor and the Risk Manager to ensure that the facility meets the requirements. |
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 a review of the October 2020 through October 2021 fire drill logs, the facility failed to document a fire drill during sleeping hours at least every 6 months. During this time an overnight drill was only conducted on August 2, 2021.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Overnight fire drills will be conducted by Maintenance Staff at least every 6 months and documented on the Fire Drill Report Form. Tracking of the drills will be completed by the Maintenance Supervisor and the Risk Manager to ensure that the facility meets the requirements. The December 2021 fire drill will be conducted as an overnight drill and will be completed on or before December 31, 2021 to meet the regulation and to ensure compliance with the standard. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information in two out of twelve records reviewed, as there were forms that were missing documentation that a copy of the client consent was offered to the client.Client #12 was admitted on October 31, 2021 and was still active at the time of the inspection. A consent dated October 26, 2021 to a medical facility did not document if the client was offered a copy of the consent.Client #13 was admitted on November 11, 2021 and was still active at the time of the inspection. A consent dated November 2, 2021 to a medical facility did not document if the client was offered a copy of the consent. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An all-staff training was conducted by the CEO and Risk Manager on 11/30/2021; to train the staff on the completion of consents and ensuring all documentation is completed in entirety and reviewed prior to staff signing the documentation. Maintaining compliance will be tracked through monthly chart audits by the Clinical Director and Director of Nursing. |