INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 2, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Harwood House 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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705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection on December 2, 2024, the facility failed to store the cooking utensils in an enclosed area after each usage.
The utensils were in an unenclosed area in the kitchen at 02:45 p.m., between the lunch and dinner meals.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the food coordinator to assure that all cooking utensils are in an enclosed area after each usage. All outside storage containers for utensils were removed by the food coordinator. The food coordinator has been trained in this by the executive director on 12/3/2024.All staff will be trained via email/text on 12/6/2024 and in person on 12/18/2024 to observe that all kitchen utensils are in an enclosed area. It is the responsibility of the program supervisors to ensure this standard.
It is the responsibility of the program director to ensure overall compliance. |
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 eight client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in two of two applicable records reviewed.
Client # 3 was admitted on April 30, 2024 and was discharged Against Staff Advice (ASA) on July 3, 2024. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
Client # 4 was admitted on March 20, 2024 and was discharged Against Staff Advice (ASA) on June 11, 2024. The facility failed to follow their policy related to ASA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
It is the responsibility of the client's counselor to notify the client's emergency contact on record within twelve hours if the client leaves treatment Against Staff Advice (ASA) or goes Absent Without Leave (AWOL)
It is the responsibility of the counselor to enter a miscellaneous note indicating the time the client left treatment, the time the emergency contact was notified and the emergency contact's first and last name, their relationship to the client and the phone number.
If a client leaves treatment AMA or AWOL and not clinical staff if present in the facility, it is the responsibility of the program worker on duty to notify the clinical supervisor and program worker supervisor that the client has left treatment. The program worker supervisor will then contact the client's emergency contact and complete a miscellaneous note within twelve hours that the client left treatment, containing the above information.
The staff, program worker supervisor and counselors were trained on this documentation on 12/6/2024.
it is the responsibility of the clinical supervisor to ensure that notification of emergency contact is notified related to ASA discharges within twelve hours and that it is documented in a note.
It is the responsibility of the program director to ensure overall compliance. |
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 eight client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in six records reviewed.
Client # 1 was admitted on June 18, 2024 and was discharged on September 17, 2024. The record contained documentation of identifying information and lab work released to an outside laboratory on August 26, 2024 and September 9, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
Client # 2 was admitted on July 3, 2024 and was discharged on October 3, 2024. The record contained documentation of identifying information and lab work released to an outside laboratory on July 29, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
Client # 3 was admitted on April 30, 2024 and was discharged on July 3, 2024. The record contained documentation of identifying information and lab work released to an outside laboratory on April 30, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
Client # 5 was admitted on November 13, 2024 and was discharged on November 14, 2024. The record contained documentation of identifying information and lab work released to an outside laboratory on November 13, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
Client # 6 was admitted on September 5, 2024 and was active at the time of the inspection. The record contained documentation of identifying information and lab work released to an outside laboratory on September 5, 2024 and November 2, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
Client # 7 was admitted on September 10, 2024 and was active at the time of the inspection. The record contained documentation of identifying information and lab work released to an outside laboratory on November 9, 2024; however, there was no documentation that the facility obtained a release of information prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the clinical supervisor to update consents as needed. The clinical supervisor added the consent for outside lab in the client record on 12/4/2024.
It is the responsibility of staff completing the intake to review with the person and have the person sign the consent for the outside lab on the day of intake admission.
It is the responsibility of the counselor to have all active clients on their caseload review and sign the consent to release information form to the lab during their sessions by 12/20/24. The counselors will be trained in this by 12/13/2024.
It is the responsibility of the clinical supervisor to meet with the clinical team on 12/9/2024 to review the persons client record during intake session to ensure that all consents are included in the client record.
It is the responsibility of the clinical supervisor to ensure that all active clients sign the lab consent.
It is the responsibility of the clinical supervisor to ensure that outside lab consent is in the client record.
it is the responsibility of the program director to ensure overall compliance. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of eight client records, the facility failed to document that the client was given the opportunity to request reconsideration of a decision terminating treatment in one of one applicable record reviewed.
Client #1 was admitted on June 18, 2024 and was administratively discharged on September 17, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the staff person notifying the client of termination to document in a miscellaneous note that the client was told they have the right to file the compliant and grievance form that is in their handbook if they want reconsideration of a decision terminating treatment. Stall will be trained on this documentation procedure on 12/9/2024 during staff meeting.
it is the responsibility of the clinical supervisor to ensure the documentation is completed.
It is the responsibility of the program director to ensure overall compliance. |
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 client records, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within 30 days of discharge, per facility policy, in two of four applicable records reviewed.
Client # 3 was admitted on April 30, 2024 and was discharged on July 3, 2024. The record contained follow-up information; however, it was not dated to confirm it was completed within the timeframe of the facility policy.
Client # 4 was admitted on March 20, 2024 and was discharged on June 11, 2024. The record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the staff member assigned to complete follow-up information within 30 days of discharge to ensure the date is documented on the form withing the timeframe of 30 days. Staff member was trained on 12/3/2024.
It is the responsibility of the counselor to place the follow-up information form in the follow up binder so the staff member can make the follow-up call. Counselors were trained on 12/3/2024.
It is the responsibility of the clinical supervisor to ensure that the information is in the follow-up book and that all forms have the date.
It is the responsibility of the program director to ensure overall compliance. |