INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and complaint investigation conducted on July 22, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Allegiance Rehabilitation Center, Inc. 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of six personnel records, the facility failed to instruct one employee on the use of the fire extinguishers upon staff employment.
Employee #1 was hired on April 26, 2021 and was current in that position. Employee #1 did not receive instruction on the use of fire extinguishers until June 24, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All newly hired staff will be trained on their date of hire regarding the use of the fire extinguishers and documented in the employee's personnel file.
All supervisors will be re-trained by the Safety Officer with regard to having newly hired staff trained on Use of
the Fire Extinguishers upon hire.
Training will be completed by the
Safety Officer no later than September 30, 2021
Sign in at the training will serve as
proof of attendance and compliance.
On going compliance will be monitored
through quarterly audits by the HR
Manager of the Staff Training records of all newly hired employees. If
compliance falls below 100%,
retraining of the Supervisors will be
completed by the Project Director and the HR Manager. |
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 five fire drills, the facility failed to maintain a written fire drill record including the exit route used in all drills reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Maintenance Department staff will be retrained by the Safety Officer, with regard to specifying what exit route was utilized during fire drills as well as identifying available alternate routes and documentation of the same. Staff retraining will be completed no later than September 30, 2021. Attendance Sign in will serve as proof of training and compliance. All Fire Drill records will be reviewed monthly for accuracy and compliance by the Safety Officer. Any deficiencies will be reviewed with the Project Director and a plan of correction will be developed by the Safety Officer to ensure on-going compliance. Compliance is expected to be 100% If compliance falls below this benchmark, the Safety Officer will be retrained by the Project Director with regard to specifying exit routes utilized and alternate routes available during the drill. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of five fire drills, it could not be determined if the facility prepared alternate exit routes to be used during fire drills, as no exits were identified on the written fire drill record in all drills reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Maintenance Department staff will be retrained by the Safety Officer regarding written Fire Drill records and the identification of exit routes utilized and alternate exit routes being identified. The re-training of Maintenance staff will be completed by the Safety Officer no later than September 30, 2021. Sign in will be evidence of training and compliance. Fire Drill logs will be reviewed monthly for accuracy and compliance by the Safety Officer. Any deficiencies will be reviewed with the Project Director and a plan of correction will be developed by the Safety Officer to ensure on-going compliance. Compliance is expected to be 100% If compliance falls below this benchmark, the Safety Officer will be retrained by the Project Director with regard to specifying exit routes utilized and alternate routes available during the drill. |
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
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Observations
Based on a review of documents submitted by the facility, they facility failed to make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will make available to the public an annual report which includes, but not limited to: a statement disclosing the names of officers, directors and principal shareholders, when applicable. A report that includes the names of directors and principal shareholders will be made available no later than October 30, 2021 |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on a review of documents submitted by the project during the licensing process, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The project will obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
This audit will be completed no later than October 30, 2021 |
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 ten client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one record reviewed.
Client #7 was admitted on February 24, 2021 and discharged on June 1, 2021. Documentation was found in the client record that on May 25, 2021, the project released a presence in treatment letter to a county with which the client did not reside and without an informed and voluntary consent signed by the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Support staff and Clinical staff will
be retrained regarding obtaining
properly documented informed and
voluntary consent from the client for the disclosure of information contained in the client record. All currently
employed support and clinical staff will be retrained by the Clinical Supervisor no later than September 30, 2021 with regard to obtaining proper voluntary consent for the disclosure of
information contained in the record. A monthly audit of randomly selected
charts will be performed by the
Clinical Supervisor to ensure on-going compliance. Should compliance fall below 85%, a retraining of support and clinical staff will be held as well as
progressive disciplinary should the
audit yield a re-occurring pattern
specific to an employee.
Training sign-in will serve as proof of employee attendance and compliance with this plan. The Clinical Supervisor will share audit findings on a monthly basis to ensure compliance with this plan. |
709.32 (c) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
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Observations
Based on a review of the project ' s Medication Control policy and procedures as well as observing medication administration at 12:50pm on July 22, 2021, the facility failed to implement a written policy and procedure regarding all medications used by clients. The project ' s procedure states that " nursing staff will then observe the client take the medication, checking their mouth to make sure the medication was swallowed properly. Client ' s mouth will then also be checked by staff outside the medication area to ensure the medication was swallowed. "
There was not a staff outside of the medication area checking the client ' s mouth to ensure the medication was swallowed properly.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Nursing will retrain BHT and Nursing staff regarding the written policy
and procedures with regard to medications used by clients which shall include, but not limited to following the procedure whereas another staff member will check the client's mouth outside of the medication dispensing area to ensure medication was swallowed. The training sign in will be utilized
to prove attendance and compliance.
Training will occur no later than September 30, 2021. On-going compliance will be
monitored by Director of Nursing or Charge RN and the BHT Manager through random observation of medication administration on a monthly basis and recorded. Any failure of a staff member to check the client's mouth outside of the Medication Administration
area, will result in retraining of the policy
and progressive discipline should the
observation yield a consistent pattern with a particular staff member. All non-compliance with the policy will be reported to the Project Director. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of ten client records, facility failed to review, and update treatment and rehabilitation plans at least every 30 days in three records reviewed.
Client # 6 was admitted on April 28, 2021 and was current at the time of the inspection. Client # 6 had a treatment and rehabilitation plan dated May 11, 2021 and the next was due to be updated by June 11, 2021. There was no documented update until July 8, 2021.
Client # 7 was admitted on February 24, 2021 and was discharged on June 1, 2021. Client # 7 had a treatment and rehabilitation plan dated March 3, 2021 and the next was due to be updated by April 3, 2021. There were no documented updates prior to the client ' s discharge on June 1, 2021.
Client # 9 was admitted on April 16, 2021 and discharged on June 9, 2021. Client # 9 had a treatment and rehabilitation plan dated April 22, 2021 and the next was due to be updated by May 22, 2021. There were no documented updates prior to the client ' s discharge on June 9, 2021.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will retrain all clinical staff with regard to treatment plan reviews being completed at least every 30 days. For those whose treatment regime is less than 30 days, the treatment and rehabilitation plan will be reviewed and updated at least every 15 days. This training will be completed no later than September 30, 2021, evidenced by training sign- in as proof of attendance and compliance with this plan. The Clinical Supervisor will conduct monthly audits of randomly selected records to ensure on going compliance of at least 85% of all records reviewed. Should compliance fall below 85%- the Clinical Supervisor will retrain staff and follow progressive discipline should the audit yield a pattern specific to a particular staff member. Documentation of audit findings will be reviewed on a monthly basis with the Project Director as well as any disciplinary/retraining that may be required. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of ten client records, the project failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan, in three records reviewed.
Client # 4 was admitted on July 10, 2021 and was current at the time of the inspection. Client # 4 had a treatment and rehabilitation plan dated July 16, 2021 that indicated daily groups. Client # 4 was missing documentation for group on July 17, 2021 and July 18, 2021.
Client # 7 was admitted on February 24, 2021 and was discharged on June 1, 2021. Client # 7 had a treatment and rehabilitation plan dated March 3, 2021 that indicated individual sessions weekly. Client # 7 did not have documentation of individual sessions for the weeks of March 22, 2021 - March 28, 2021; March 29, 2021 - April 4, 2021; May 3, 2021 - May 9, 2021; May 10, 2021 -May 16, 2021, May 17, 2021 - May 23, 2021; and May 24, 2021 - May 30, 2021.
Client # 9 was admitted on April 16, 2021 and discharged on June 9, 2021. Client # 9 had a treatment and rehabilitation plan dated April 22, 2021 that indicated individual sessions weekly. Client # 9 did not have documentation of individual sessions for the weeks of May 17, 2021 - May 23, 2021; May 24, 2021 - May 30, 2021; and May 31, 2021 - June 6, 2021.
These findings were discussed with project staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will retrain all clinical staff with regard to assuring that counseling services are provided in accordance to the individual treatment and rehabilitation plan. This training will be completed no later than September 30, 2021, evidenced by training sign- in as proof of attendance and compliance with this plan. The Clinical Supervisor will conduct monthly audits of randomly
selected records to ensure on going
compliance of at least 85% of all records reviewed. Should compliance fall below 85%- the Clinical Supervisor will retrain staff and follow progressive discipline should the audit yield a pattern specific to a particular staff member. Documentation of audit findings will be reviewed on a monthly basis with the Project Director as well as any disciplinary/retraining that may be required. |
709.52(e)(1) LICENSURE Medical/dental support services
709.52. Treatment and rehabilitation services.
(e) The project shall assist the client in obtaining the following supportive services when necessary:
(1) Medical/dental.
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Observations
Based on a review of ten client records, the project failed to assure that one client was assisted in obtaining medical/dental supportive services when necessary.
Client # 7 was admitted on February 24, 2021 and was discharged on June 1, 2021. The client arrived at the facility on February 24, 2021 with an extremity boot for an ankle fracture that occurred 2 weeks prior.
Medical documentation in the client record from a hospital dated March 17, 2021 indicated the client went to the hospital for back pain and to have the ankle x-rayed. The documentation stated the client was to follow up with a separate provider on March 18, 2021; however, there was no documentation this occurred in the client record. The documentation from the hospital also stated the client was to follow up with a pain management clinic within one-two weeks; however, there was no documentation this occurred in the client record.
These findings were discussed with project staff during the licensing process.
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Plan of Correction
The Director of Nursing will retrain all licensed nursing staff with regard to assisting the client in obtaining the following services when necessary: (1) Medical/Dental no later than October 30, 2021. Attendance sign in will serve as proof of compliance with this plan. All documentation following a medical or dental appointment will be reviewed with the Director of Nursing, Charge Nurse or Physician (on-call or at site) with 24 hours of the return of the client to the facility. The instructions following such supportive service appointments will be followed with regard to scheduling and documenting any ordered follow up care. The nursing staff will attempt to schedule any consults within 72 hours of the resident returning. All attempts of making the appointments will be documented under the Nurses Progress Note section of the client's chart. Compliance will be monitored through documented, random monthly chart audits completed by the Director of Nursing. Compliance will not fall below 85% of all charts audited during that month. Should the score fall below the benchmark of 85% |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of ten client records. The facility failed to compete a discharge summary in one of four applicable client record reviewed.
Client # 7 was admitted on February 24, 2021 and was discharged on June 1, 2021. There was no documentation of a discharge summary in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will retrain all Clinical staff with regard to completing a a Discharge summary for every client that discharges from the Inpatient program within 7 days from date of discharge. Training will be completed no later than September 30, 2021. Signature of attendance will serve as compliance with this plan. The Clinical Supervisor will complete a monthly audit of randomly selected charts to ensure ongoing compliance. Should the audit fall below 85% compliance, the Clinical Supervisor will retrain Clinical Staff with regard to completing discharge summaries within 7 days of discharge date, the Clinical Supervisor will retrain Clinical staff, if audit findings yield identification of a pattern to a particular staff, that staff will receive progressive disciplinary. The audit findings will be documented and shared with the Project Director monthly, as well as any retraining or disciplinary action. |