INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 19, 2022 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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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 personnel records, the facility failed to ensure that each employee had a written, annual individual training plan, developed with input from the employee and supervisor, documented in the record in one of six personnel records reviewed.
Employee #6 was hired as a counselor assistant on October 25, 2021. The individual training plan for the current 2022-2023 training year was not signed by the employee or the supervisor as of the date of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The supervisor meeting with the employee reviewing the individual training needs assessment annually shall develop the written individual training plan with the employee, have the employee sign and date the form and the supervisor will sign and date the form. Lines for signatures/dates were added to the form.
Changes to this were made on 12/22/2022.
The clinical supervisor is responsible for checking all forms once submitted.
The executive director is responsible for the overall compliance of this form. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors/facility directors during the facility's July 1, 2021 through June 30, 2022 training year in one of one applicable personnel record reviewed.
Employee #1 was hired as the project director/facility director on April 23, 2009. The record documented 10.5 hours of annual training for the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the facility director to obtain 12 hours of training yearly and is responsible for scheduling the 12 hours training and obtaining a certificate of training attendance
The Board of Directors are responsible for the overall compliance of this directive.
The program director is compliant with having 12 clock hours of training for the current year as of 12/26/2022.
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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 a review of client records, the facility failed to ensure that a copy of a client consent form was offered to the client in six of seven client records reviewed.
Client #1 was admitted on October 19, 2022 and was active at the time of inspection. There was a release of information form to a healthcare agency signed and dated by the client on October 19, 2022; however, there was no documentation that indicated a copy of the consent form was offered to the client.
Client #2 was admitted on October 10, 2022 and was active at the time of inspection. There was a release of information form to a healthcare agency signed and dated by the client on October 10, 2022; however, there was no documentation that indicated a copy of the consent form was offered to the client.
Client #3 was admitted on September 7, 2022 and was active at the time of inspection. There was a release of information form to a healthcare agency signed and dated by the client on September 7, 2022; however, there was no documentation that indicated a copy of the consent form was offered to the client.
Client #5 was admitted on April 26, 2022 and was discharged on June 26, 2022. There was a release of information form to a government agency signed and dated by the client on April 26, 2022; however, there was no documentation that indicated a copy of the consent form was offered to the client.
Client #6 was admitted on October 5, 2022 and was discharged on November 10, 2022. There was a release of information form to a healthcare agency signed and dated by the client on October 5, 2022; however, there was no documentation that indicated a copy of the consent form was offered to the client.
Client #7 was admitted on September 1, 2022 and was discharged on November 26, 2022. There was a release of information form to a healthcare agency signed and dated by the client on September 1, 2022; however, there was no documentation that indicated a copy of the consent form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the employee completing the admission to ensure that a copy of the client consent forms is offered to the client and checked in the client record that the consent was offered.
The project director met with the clinical supervisor and persons completing the admission stating that all copies of consents are to be offered to the client, and proper documentation evidenced by checking off yes at bottom of the consent for offering the consents to the person was completed on 12/22/2022.
Client #1,2,3- counselor will review consents with clients #1,2,3 and offer the person a copy of the release of information form to a healthcare agency and document that the consent was offered in a note to chart.
The project director met with the clinical supervisor on 12/22/2022 to ensure that proper documentation is completed by completing chart checks on all admission client records within 2 days of admission to ensure that copies of consents are offered to the client. If the consent was not offered, the clinical supervisor will offer the consent to the person at that time.
The project director is responsible for overall compliance. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgment by the client that the client had been informed of their right to retain civil rights and liberties except as provided by statute in all seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the project director to update Client Rights policy and procedure, client rights consent form and client handbook to say verbatim client rights 709.30 from standards
This was completed on 12/22/2022.
It is the responsibility of the project director for overall compliance. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to document the written acknowledgement by the client that the client had been informed of their right to inspect their own records in all seven of seven client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the project director to update Client Rights policy and procedure, Client Rights consent and client handbook to include (3) that clients have the right to inspect their own record.
All three forms were updated on 12/23/2022.
the project director met with clinical supervisor to review updated forms. Clinical staff will be informed during their staff meeting on 12/26/2022 of the changes to the forms.
program workers will be informed during their monthly staff meeting on 1/16/2023. Updated client rights form was submitted to be placed in the electronic system on 12/23/2022. The client rights consent was posted in common area of house on 12/26/2022.
the project director is responsible for overall compliance. |