INITIAL COMMENTS
|
This report is a result of an on-site complaint investigation conducted on February 25-26, 2025, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, James A. Casey House, LLC was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
|
Plan of Correction
|
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
During a complaint investigation conducted on February 25-26, 2025, the facility failed to have a hot water temperature not exceed 120 It was observed the staff bathroom located in the administrative office had a hot water temperature of 148
|
Plan of Correction
Project Director informed Maintenance Supervisor of the high water temperature (148F) in the staff bathroom. Project Director instructed Maintenance to monitor the water temperature on a weekly basis to ensure that it does not exceed 120F. |
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.
|
Observations
Based on a review of client records, administrative documentation, and staff interviews, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information.The facility Confidentiality policy indicates Federal and State Law prohibit the disclosure of any client identifying data to any outside agency or person unless appropriate releases have been obtained from the client. Client # 6 was admitted December 10, 2024, and discharged February 19, 2025. Client identity was released to law enforcement on January 23, 2025. There was no documentation of an informed and voluntary consent in the client record.
|
Plan of Correction
Confidentiality training, presented by Project Director and Clinical Director will be conducted for all staff on 4/1/2025.
All staff is required to complete the DDAP Substance Use Disorder Confidentiality training by the end of the year, as well. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of administrative documentation during a complaint investigation conducted on February 25-26, 2025, it was observed the facility failed to submit a written unusual incident report to the Department within 3 business days following an event requiring the presence of policy, fire or ambulance personnel. Police, fire, and/or ambulance personnel responded to events at the facility on 10/26/24, 10/28/24, 11/9/24, 11/18/24, 1/2/25, 1/23/25, 1/24/25, and 2/2/25. The Department was not notified of these incidents as required.
|
Plan of Correction
Project Director and or Clinical Director will report the events on site that police, fire and/or ambulance personnel respond to.
Project Director informed house staff to document all calls made to emergency personnel in a log book for facility and documentation purposes.
This process began on 2/25/2025. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document the frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in two of seven records reviewed.Client # 4 was admitted August 28, 2024, and discharged December 13, 2024. The treatment plan dated August 28, 2024, did not have the frequency of treatment services indicated. Client # 7 was admitted September 9, 2024, and discharged January 7, 2025. The treatment plan dated September 9, 2024, did not have the frequency of treatment services indicated.
|
Plan of Correction
Client #4 was admitted on August 28th, 2024 and Client #7 was admitted on September 9th 2024. On September 18th 2024, Frequency of Treatment was implemented into all treatment plans moving forward.
Clinical Director will provide training during the first week of hire for new counselors on proper treatment plan writing. Clinical Director will also provide updated treatment plan training to all clinical staff on a monthly basis.
Clinical Director and Project Director will review and in-house audit charts on a weekly basis to ensure all frequencies of treatment are documented, and will also ensure that all treatment plans are up to date with current regulations.
|