INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 29, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, My Sister's Place Thomas Jefferson University 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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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection, the facility failed to ensure that all heaters were permanently mounted or installed.At the time of the inspection, a space heater was found in the nursing office.This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Residential Clinical Director and Operations Director will review with all staff that space heaters or any heater that is not permanently mounted or installed are not permitted in the facility. This will be reviewed in weekly treatment team meeting on 12/12/2023 followed up with an email to all staff to ensure everyone was made aware.
The heater was removed from the facility immediately on 11/29/2023
This Plan of Correction will be implemented by 12/18/2023.
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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 facility's January 2023 through October 2023 fire drill logs, the facility failed to include, on the fire drill log, the amount of time it took for evacuation and whether the fire alarm or smoke detector was operative during a fire drill conducted on the April 5, 2023. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure the Record of Fire Drill Log is completed correctly and in its entirety, Residential Operations Director and Residential Operations Supervisor will review how to complete the form with their staff at their next mandatory staff meeting on 12/21/2023.
This will be reviewed independently with anyone who is not in attendance at this meeting.
Residential Operations Supervisor will check the log to ensure its completed following any unannounced or actual drill.
Staff will sign a memo that they have received and acknowledge this training that will be added to their employee file.
For all BHTs that are hired after 12/21/23, Residential Operations Supervisor or designee will review this form during their training period ensuring that they understand the importance of completing the form in full.
This Plan of Correction will be implemented by 1/1/2024
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711.52(a)(3) LICENSURE Mngt of Tx Services- Written Procedures
711.52. Treatment and rehabilitation services.
(a) The project shall adopt a written plan for the coordination of client treatment and rehabilitation services, which shall include, but not be limited to:
(3) Written procedures for the development, approval and ongoing management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual and client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of two applicable client record reviewed. Per the policy and procedure manual, the program will contact the participant's emergency contact within 24 hours when the participant leaves treatment against facility advice.Client #6 was admitted on May 16, 2023 and was discharged against facility advice on July 25, 2023. There was no attempted emergency contact notification documented in the record at the time of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Residential Clinical Director and Clinical Supervisor will review My Sister's Place policy and procedures as it relates to contacting the participant's emergency contact within 24 hours when the participant leaves treatment against facility advice, with clinicians and patient navigation team.
Acknowledgement of this call being completed has been added to the discharge summary which is completed by clinical staff during discharge process. In clinical group supervision the change in form will be reviewed on 12/13/2023.
Clinical Supervisor will review all records as discharges take place to ensure that emergency contacts are called within 24 hours of discharge.
This Plan of Correction will be implemented by 12/18/2023.
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