INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 22, 2022 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on one of six employee personnel records reviewed, the facility failed to provide documentation of the qualification of counselors for employee # 3.Employee # 3 was hired as a counselor on August 8, 2022 and was still in this position at the time of the inspection. Based on a review of employee # 3's personal record and resume, employee #3 did not meet the educational requirements to be a counselor. At the time of the hire, the employee had a high school diploma, which is a non-qualifying degree for the position of counselor.These findings were reviewed with facility staff during the licensing process
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Plan of Correction
As of 11/22/2022, the job title and duties of Employee #3 were changed to Counselor Assistant. The citation was explained to the employee, as were the new duties and job title, by the Clinical Director. Until such time which the employee satisfies the education and experiential requirements, she will operate as a Counselor Assistant under the supervision of the Clinical Director. The Counselor Assistant is in her last semester of her Bachelor Degree and working toward her CADC.
The Director of Human Resources will complete a full initial audit of employee files, to ensure education, experience, and licensing requirements are met, to be completed by 1/31/2023. Thereafter, quarterly audits will take place for all newly hired employees. The file audit results will be shared with the performance improvement committee on a quarterly basis for a period of one year.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of six personnel records, the facility failed to provide a written individual training plan to include documentation of input from both the employee and the supervisor in all six personnel records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An annual training plan template will be created on 1/6/2023 and implemented no later than 1/20/2023, for the 2023 training plans. Going forward, all supervisors or directors will complete the annual training plan concurrently with annual competency and performance evaluations with each direct report. Annual competencies, performance evaluations and training assessments will drive the content of the annual training plan. Each staff member and the Supervisor will sign the form and it will be used for the 2023 training plans. This annual requirement has been added to HR audits to ensure compliance. Compliance with the annual requirement will be reported to the performance improvement committee. |
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, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. A camera was observed in the library group room. In addition, the wellness building annex group room could be heard from outside of the room and the wellness group room had large windows and a group session was observed from outside of the building.These findings were reviewed with facility staff during the licensing process
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Plan of Correction
The Maintenance Director removed the cameras from all group rooms and sound machines were provided for all areas where confidential sessions take place on 11/23/2022. Permanent window coverings will be installed in the facility by 2/28/2023 and the Maintenance Director is overseeing the project. Temporarily, the facility has moved the groups to alternative locations on campus where the windows are covered to ensure privacy and confidentiality of sessions. The facility will complete daily leadership rounds to ensure the corrections have been maintained and issues will be corrected in real-time. Results of the daily leadership rounds will be discussed during performance improvement committee meetings. The facility will also conduct privacy rounds bi-annually to ensure all aspects of privacy and confidentiality are maintained, with results being reported to the performance improvement committee. |
705.5 (j) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(j) A residential facility shall prohibit smoking and use of candles in bedrooms.
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Observations
Based on a physical plant inspection, the facility failed to prohibit smoking and use of candles within bedrooms as it was observed that in Sycamore building's downstairs bathroom had ash around the toilet and sink and Spruce building bedroom 5 had a makeshift ash trash next to the bed containing a cigarette butt and ashes. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has designated smoking areas, no-smoking signage posted and the clients are educated on the smoking policy at Orientation and it is written in the Client Handbook that every client receives. The clients assigned to the rooms mentioned were addressed individually by the Clinical Director and Counselors on 11/22/2022. The Community was also addressed by the Clinical team on 11/22/2022. Additional signage will be posted at the facility with a completion date of 1/13/2023. The facility will complete daily leadership rounds which will include inspection of patient bedrooms and bathrooms, starting on 1/6/2023. Any issues discovered during daily leadership rounds will be immediately addressed and corrected. Results of daily leadership rounds will be discussed during daily leadership meetings to ensure issues are address with patients found to be in violation. Violations will be recorded as an incident report. Data from daily leadership rounds and incident reports will be reviewed monthly as part of performance improvement committee activities. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all client bathrooms located within the bedroom areas were supplied with paper towels or a mechanical dryer. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The facility received an estimate on 12/20/2022 for installation of mechanical hand dryers in each bathroom. The installation of mechanical hand dryers is estimated to be completed by 3/31/2023. Temporarily, each restroom is supplied with paper towels by housekeeping staff. Daily leadership rounds include inspection of bathrooms to ensure supplies remain stocked and issues are corrected immediately in real-time. Results of daily leadership rounds will be shared with the leadership team each morning to ensure temporary measures are consistently being followed until the permanent hand dryers are installed. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on four of fourteen client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to include the purpose of the disclosureClient # 10 was admitted on November 10, 2022 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information dated November 10, 2022 to a probation office did not include the purpose of the disclosure.Client # 12 was admitted on September 3, 2022 and was discharged on October 2, 2022. An informed and voluntary consent from the client for the disclosure of information dated September 4, 2022 to a probation office did not include the purpose of the disclosure.Client # 13 was admitted on August 29, 2022 and was discharged on October 12, 2022. An informed and voluntary consent from the client for the disclosure of information dated September 2, 2022 to a probation office did not include the purpose of the disclosure.Client # 14 was admitted on September 8, 2022 and was discharged on October 21, 2022. An informed and voluntary consent from the client for the disclosure of information dated September 8, 2022 to a probation office did not include the purpose of the disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Admissions will educate/train staff on the proper completion of consents by 1/13/2023. The staff will complete attestation forms for this education/training. An audit will be completed for all current patients by 1/13/2023 for accurate completion of consents. Going forward, all newly signed consents will be audited by the Director of Admissions for accurate completion prior to being placed in the chart until a goal of 100% compliance for 60 consecutive consents has been reached. Issues will be corrected in real time and results will be reported during daily leadership meetings. After the 60 admissions, the Admissions Director will track completion with monthly audits. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on five of fourteen client records reviewed, the facility failed to provide documentation of medication being provided as prescribed by a physician.Client # 5 was admitted on October 2, 2022 and was discharged on October 8, 2022. The client was prescribed medications to be taken daily; however, after a review of the facility medication administration records, there was no documentation of the medications being given on:Fluoxetine 40 mg- October 4, 2022Topiramate 1000mg- October 4, 2022 Client #7 was admitted on October 10, 2022 and was discharged on October 15, 2022. The client was prescribed medication to be taken daily; however, after a review of the facility medication administration records, there was no documentation of the medications being given: Thiamine 100mg- October 13, 2022 and October 14, 2022folic acid 1mg- October 13, 2022 and October 14, 2022B-12 1000mg- October 13, 2022 and October 14, 2022Client #8 was admitted on October 18, 2022 and was still active at the time of the inspection. The client was prescribed medications to be taken daily; however, after a review of the facility medication administration records, there was no documentation of the medications being given on:Depakote 1000 MG- November 17, 2022Protonix 20mg -November 15, 2022 and November 17, 2022 Clindamycin 300mg- November 15, 2022, November 16, 2022 and November 18, 2022Gabapentin 400mg- November 19, 2022Prazosin 1mg- November 14, 2022 Client #9 was admitted on November 2, 2022 and was discharged on November 22, 2022. The client was prescribed medication to be taken daily; however, after a review of the facility medication administration records, there was no documentation of the medications being given on: Thiamine 100mg- November 11, 2022Folic Acid 1mg - November 11, 2022Effexor 150mg- November 11, 2022 Propranolol 20mg-November 7, 2022 and November 11, 2022Lamictal 100mg- November 11, 2022 Prazosin 1mg- November 11, 2022Seroquel 200mg- November 11, 2022Client #13 was admitted on August 29, 2022, and was discharged on October 12, 2022. The client was prescribed medication to be taken daily; however, after a review of the facility medication administration records, there was no documentation of the medication being given on :Prozac 10 mg -September 2, 2022, September 7, 2022, October 4, 2022 and October 8, 2022Cogentin 1mg- September 2, 2022, September 7, 2022, October 4, 2022 and October 8, 2022 Wellbutrin 100mg - September 1, 2022, September 2, 2022, September 7, 2022, October 4, 2022 and October 8, 2022These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Nursing will educate/train staff on the proper completion of the Medication Refusal Form by 1/13/2023. The Director of Nursing will also put in place processes for monitoring medication compliance, and notification of missing or incorrect documentation in the MAR. The nursing staff will sign attestation forms acknowledging the education/training they received on this issue. The Director of Nursing will monitor the first 60 admissions for the proper completion of the Medication Refusal Form to ensure 100% compliance. After the 60 admissions, the Director of Nursing will track completion with monthly audits. Results of audits will be discussed during leadership meetings. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of seven inpatient client records reviewed, the facility failed to ensure complete client record on an individual which is to include a record of the services provided in three client records. Client #12 was admitted on September 3, 2022 and was discharged on October 2, 2022. The client record failed to contain a completed record of the services provided. Client #13 was admitted on August 29, 2022 and was discharged on October 12, 2022. The client record failed to contain a completed record of services provided. Client #14 was admitted on September 8, 2022 and was discharged on October 21, 2022. The client record failed to contain a completed record of services provided. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Record of Service Document was created on 11/22/2022 by the Clinical Director. The Clinical Staff will be educated and trained on the use of this form by the Clinical Director. The Clinical Director will monitor the first 60 admissions for the proper completion of the Record of Service Form to ensure 100% compliance. After the 60 admissions it will be monitored through monthly chart audits. The Clinical staff will sign attestation forms acknowledging the education/training they received on this issue by 1/13/2023. |