INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 6-7, 2024, 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.
|
Plan of Correction
|
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.
|
Observations
Based on a physical plant inspection, the facility failed to not permit facility heaters that are not permanently mounted or installed. A portable space heater was observed by DDAP staff in the chart room located in the Sycamore building.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The portable space heater was removed from the chart room/DON office on 11/6/2024. All staff was re-educated by the Director of Environment of Care and Risk Manager at the monthly staff meeting on 11/19/2024 that portable heaters are not permitted at the facility. The Director of Environment of Care will monitor with monthly campus inspections for 100% compliance. |
709.28 (a) (2) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(2) Identification of project staff having access to records, and the methods by which staff gain access.
|
Observations
Based on a review of facility client records, the facility failed to adhere to it's confidentiality policy in regards to identification of project staff having access to records, and the methods by which staff gain access.
The facility's policy notes that the Facility Director, as well as other select staff, will have access to client records. At the time of the onsite inspection, the Facility Director was unable to provide access to any of the outpatient client records required by DDAP to complete the inspection.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
At the weekly department meeting on 12/3/2024, the Director of Clinical Services will re-train all Clinical staff on the importance of documenting in the electronic medical record system (HCS) and uploading any paper documents so that all client records are accessible per facility policy and DDAP regulation. The Director of Clinical Services and the CEO will audit charts on a weekly basis for the first 3 months to ensure 100% compliance. After the 3 months, compliance will be monitored through monthly chart audits. The Clinical staff will sign attestation forms acknowledging the education/training they received on this issue. |
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.
|
Observations
Based on a review of the detox client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of seventeen client records reviewed.
Client #1 was admitted on March 8, 2024, and discharged on March 15, 2024. Two release of information forms for a funding source and an emergency contact, both dated March 12, 2024, did not have documentation that the client was offered a copy of the consent form.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
On 11/26/2024, the Director of Admissions re-trained the Admission staff on the proper completion of consents and staff signed attestation forms for the training. Consents will be audited by the Director of Admissions for accurate completion 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. |
709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
|
Observations
Based on a review of facility client records, the facility failed to implement a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance in releationship to it's stated goals and objectives.
At the time of the DDAP onsite inspection, the facility was unable to produce any of it's outpatient client records for review.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
At the weekly department meeting on 12/3/2024, the Director of Clinical Services will re-train all Clinical staff on the importance of documenting in the electronic medical record system (HCS) and uploading any paper documents so that all client records are accessible per facility policy and DDAP regulation. The Director of Clinical Services and the CEO will audit charts on a weekly basis for the first 3 months to ensure 100% compliance. After the 3 months, compliance will be monitored through monthly chart audits. The Clinical staff will sign attestation forms acknowledging the education/training they received on this issue. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of partial client records, the facility failed to document a comprehensive treatment plan 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 comprehensive treatment plan must be completed between within seven days of admission.
Client #24 was admitted on April 24, 2024, and was discharged on October 20, 2024. A comprehensive treatment plan was due no later than May 1, 2024; however, it was completed on May 9, 2024.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Clinical Services will re-train Clinical Staff on the timely completion of chart documentation at their monthly staff meeting on 12/3/2024. The Clinical Director/Lead Counselor will audit the charts on a weekly basis for 3 months to ensure 100% compliance. After the 3 months, compliance will be monitored through monthly chart audits. The Clinical staff will sign attestation forms acknowledging the education/training they received on this issue. |
709.82(b) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days.
|
Observations
Based on a review of partial client records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of three records reviewed.
Client #23 was admitted on October 29, 2023, and discharged on April 26, 2024. A treatment plan update was completed on January 17, 2024, and the next update was due no later than February 17, 2024; however, it was completed on April 14, 2024.
These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Director of Clinical Services will re-train Clinical Staff on the timely completion of chart documentation at their monthly staff meeting on 12/3/2024. The Clinical Director/Lead Counselor will audit the charts on a weekly basis for 3 months to ensure 100% compliance. After the 3 months, compliance will be monitored through monthly chart audits. The Clinical staff will sign attestation forms acknowledging the education/training they received on this issue. |
709.82(c) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of partial client records, the facility failed to ensure that the clients received counseling services according to their individual comprehensive treatment plan in one out of three records reviewed.
Client #23 was admitted on October 29, 2023, and was discharged on April 26, 2024. A treatment plan update dated January 17, 2024, indicated the client would receive two individual sessions per week. The record of service and progress notes indicated that the client received only one individual session during the week of January 21-27, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Clinical Services will re-train Clinical Staff on the importance of following through with the documentation on the treatment plan/client record and facility policy at the next department staff meeting on 12/3/2024. The Clinical Director/Lead Counselor will audit the charts on a weekly basis for 3 months to ensure 100% compliance. After the 3 months, compliance will be monitored through monthly chart audits. The Clinical staff will sign attestation forms acknowledging the education/training they received on this issue. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
|
Observations
Based on a review of partial client records, the facility failed to ensure that the clients received individual counseling and least twice week, in one of three records reviewed.
Client #23 was admitted on October 29, 2023, and was discharged on April 26, 2024.The record of service and progress notes indicated that the client received only one individual session during the week of January 21-27, 2024.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Director of Clinical Services will re-train Clinical Staff on the importance of following through with the documentation on the treatment plan/client record and facility policy at the next department staff meeting on 12/3/2024. The Clinical staff will sign attestation forms acknowledging the education/training they received. The Clinical Director/Lead Counselor will audit the charts on a weekly basis for 3 months to ensure 100% compliance. After the 3 months, compliance will be monitored through monthly chart audits. |
709.83(a)(11) LICENSURE Client records
709.83. 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.
|
Observations
Based on a review of partial client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of three discharged records reviewed.
Client #22 was admitted on September 21, 2023, and was discharged on March 18, 2024. There was no documentation of a follow-up contact in the client record.
Client #23 was admitted on October 29, 2023, and was discharged on April 26, 2024. There was no documentation of a follow-up contact in the client record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By 12/8/2024 , The Alumni Coordinator will be trained by the Director of Business Development 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. |