INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection and buprenorphine monitoring inspection conducted on February 23-24, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, James Casey House, LLC. was found to be not 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to provide documentation of the required clinical experience in personnel record #4.Employee #4 was hired as a counselor on 8/31/2016 with a Bachelor's Degree.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Employee #4 was entered into our program as a counselor's assistant with a start date of 02/25/2017. Employee #4 has a B.A. in Psychology in accordance with 704.8 (a)(2) and will complete the training requirements (40 hrs.) indicated in 704.11 (g)(1) and will perform counseling duties under close supervision for at least the first 6 months of employment by a full-time counselor working the same shift in accordance with 704.9 (a)(b) and (c)(2). Employee #4 will be promoted to the position of counselor after meeting one of the sets of qualifications in 704.7. The Project Administrator will ensure that all prospective job applicants possess the required education and experience prior to date of hire, in accordance with Chapter 708 Staffing Requirements. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report, the facility failed to ensure that employees #8, 10, 11 and #12 received the required trainings.Employee #8 was hired as a manager on 8/22/14; the HIV/AIDS training and the TB/STD training were due to be completed by 8/22/16 but were not completed as of the date of the licensing inspection.Employee #10 was hired as a manager on 11/1/13; the HIV/AIDS training and the TB/STD training were due to be completed by 11/1/15 but were not completed as of the date of the licensing inspection.Employee #11 was hired as a manager on 1/16/15; the HIV/AIDS training and the TB/STD training were due to be completed by 1/16/17 but were not completed as of the date of the licensing inspection.Employee #12 was hired as a manager on 12/5/14; the HIV/AIDS training and the TB/STD training were due to be completed by 12/5/16 but were not completed as of the date of the licensing inspection.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
All counselors and other staff will receive the mandatory HIV and TB/STD trainings as required by 704.11 (c). Staff members #8, 10, 11, and #12 will be scheduled for and complete these trainings before 9/1/17 The Project Director will be responsible for ensuring that all staff have the appropriate training during their annual staff training reviews. At initial employment intake, all staff will be notified of the mandatory general training requirements. The Project Director will monitor staff training throughout the year to ensure that all staff members schedule these trainings as needed and that they attend all scheduled training. |
704.11(f)(1) LICENSURE Counselor's Trng Req
704.11. Staff development program.
(f) Training requirements for counselors.
(1) Subject areas for training shall be selected according to the training plan for each individual.
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Observations
Based on a review of the facility's Staffing Requirements Facility Summary Report and employee records, the facility failed to ensure that employee #2 received the required training hours.Employee #2 was hired as a counselor on 1/20/15 but only completed 13 documented hours of training during the January 1, 2016 through December 31, 2016 training year.This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The Project Director will regularly monitor all staff trainings throughout each calendar year to ensure compliance with 704.11. The Project Director will ensure that all staff are aware of the annual training hours required for their specific position. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection on February 23, 2017, the following deficiencies were observed.In Apartment #2 the baseboard heater cover was missing in bedrooms #2 and #4 and was damaged in bedroom #3. Additionally bedroom #3 had an area of paint and plaster peeling from the wall.In Apartment #8 the kitchen/lounge area had an electrical outlet protruding from the wall that was not secured. Additionally, Bedroom #1 had broken blinds covering the window. In Apartment #9 the bathroom mirror was sitting on the sink basin and not secured to wall. In Apartment #10 the bathroom wall near the door had an area of plaster and paint damage. Additionally, bedroom #4 had water damage to the plaster and paint above the window casement.In Apartment #11 the blinds covering the bathroom window were broken. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Apt #2, the baseboard heaters were repaired and the missing items were replaced as needed in bedrooms #2, #3, and #4. Also, in Apt #2 the damaged wall in bedroom #2 was repaired and repainted.
Apt #8, the damaged electrical outlet in the kitchen / lounge area was repaired and secured. Also in Apt #8 the damaged blinds in bedroom #2 were replaced.
Apt #9, the bathroom mirror was securely reattached to the wall.
Apt #10, the bathroom wall was repaired and repainted as needed. also in Apt #10 the damaged area above the window casement in bedroom #4 was repaired and repainted.
Apt #11, the damaged blinds in the bathroom were replaced.
The Building Maintenance Manager performs regularly scheduled weekly inspections is responsible for keeping the building and grounds clean, safe, sanitary, and in good repair at all times. |
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.
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Observations
Based on a physical plant inspection conducted on February 23, 2017, the restroom hot water temperature in apartment #2 was measured at 126.1F; Apartment #3 was measured at 123.5F and Apartment #6 was measured at 127.4F .This information was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The hot water heaters in Apts #2, #3, and #6 were adjusted and the temperatures have been set at below 120F. During weekly apartment inspections by the Building Maintenance Manager, all water temperatures will be measured to ensure that they do not exceed 120F and will be adjusted if needed. |
705.9 (4) (iii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(iii) The evacuation and transfer of residents impaired by alcohol or other drugs.
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Observations
Based on a review of the facility's Policy and Procedures manual on February 24, 2017, the facility failed to document procedures that included provisions for the evacuation and transfer of residents impaired by alcohol or other drugs.This information was reviewed with the facilit staff during the licensing inspection.
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Plan of Correction
The Project Director has amended the Facility Policy and Procedure Manual to include provisions for the evacuation and transfer of individuals impaired by alcohol or other drugs. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on February 23, 2017, the rear exit route from building 205, which passes through the hallway between apartments #3 & 4 was not properly illuminated. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
The bulbs in the light fixture at the rear exit route from Building 205 between Apts, #3 and #4 were replaced. Operational check was good. for safety reasons all interior exit lights must be illuminated at all times.
The Building Maintenance Manager performs regularly scheduled weekly inspections and will ensure that all lighting systems are operating properly. Any deficiencies will be repaired and any burned out bulbs will be immediately replaced. |
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 the facility's administrative paperwork and a conversation with facility staff on February 23-24, 2017, the facility failed to complete an annual report for fiscal year ending July 2016.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The annual report for calendar year 2016 will be posted on this facility's official website by 1 April 2017.
To prevent this deficiency from occurring in the future, the Project Director will coordinate with facility ownership and make an annual report available to the public via our official website prior to the end of each calendar year. |
709.28 (a) (1) 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:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of client #3's record on February 24, 2017, the facility failed to ensure another client's confidentiality by putting that client's full name on the psychosocial evaluation for client #3. Staff put a line through the incorrect client's name with a pen, but the of the other client was still visible. This information was reviewed with the facility staff during the licensing process.
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Plan of Correction
The offending document was removed from Client #3's chart and destroyed and was replaced on 2/27/17. The replacement document was dated and signed by client #3 and his primary counselor.
The Project Director will review proper confidentiality procedures with all facility staff during the next weekly staff meeting. Any staff members not in attendance at that meeting will be instructed on proper confidentiality procedures by the Project Director as soon as possible. |
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 client records on February 24, 2017, the facility failed to obtain a valid consent to release information in client records, #1, 2, 4, 5, & 6.Client #1 was admitted on 12/22/16 and was an active client at the time of the inspection. A consent to release information form dated 12/23/16 did not have a name or agency to whom the information was to be released. Client #2 was admitted on 1/9/17 and was an active client at the time of the inspection. Five consents, dated 1/9/17, did not specify what information was to be released, the purpose of the release or to whom the information was to be released. Client #4 was admitted on 11/9/16 and discharged on 1/4/17. A consent to an outside agency, dated 11/10/16, failed to have the date the client signed the consent. Client #5 was admitted on 10/10/16 and discharged on 1/30/17. A facsimile transmission dated 11/29/16 to an outside agency and one dated 12/5/16 were present in the client record, however no consents to release to these agencies were documented. Additionally, a consent to an outside agency, dated 11/11/16, did not specify the name or agency to whom the information was to be released. Client #6 was admitted 12/1/16 and discharged on 2/2/17. The facility failed to obtain a valid consent to the funding source. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
Charts for clients #3, #4, #5, and #6, were reviewed by the Project Director and offending documents were removed.
In the case of clients #1 and #2, who were active on the dates of the inspection, all of the incomplete and/or incorrect consent forms were corrected and/or replaced as needed. These documents were signed and dated on 2/27/17 by the clients and their primary counselors.
The Project Director will review proper confidentiality procedures, including documentation, with facility staff at the next weekly staff meeting. Any staff members not in attendance at this meeting will be instructed as soon as possible. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records on February 24, 2017, the facility failed to document a medical history in records #1 and 6.Client #1 was admitted on 12/22/16 and was an active client at the time of the licensing inspection. The facility utilized an assessment dated 4/1/16 from a previous treatment episode at the facility, but failed to update the history upon admission. Client #6 was admitted on 12/1/16 and discharged on 2/2/17. The facility utilized an assessment dated 9/26/16 from a previous treatment episode at the facility, but failed to update the history upon admission. This information was reviewed with facility staff during the licensing process.
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Plan of Correction
Previous to this inspection, client charts were normally reused for returning clients that had been discharged less than 6 months prior to readmission.
We have established a new policy whereby new charts will be initiated for all returning clients. All counselors and counselor assistants have been notified of this new policy and it will be implemented immediately.
Invalid assessment dated 4/1/16 was updated by Client #1 and his primary counselor the document was signed and dated 2/27/17 and replaced in client's chart.
The Project Director will ensure compliance by regularly reviewing client charts. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records conducted on February 24, 2017, the facility failed to document a drug and alcohol history in records #1 and 6.Client #1 was admitted on 12/22/16 and was an active client at the time of the licensing inspection. The facility utilized an assessment dated 4/1/16 from a previous treatment episode at the facility, but failed to update the history upon admission. Client #6 was admitted on 12/1/16 and discharged on 2/2/17. The facility utilized an assessment dated 9/26/16 from a previous treatment episode at the facility, but failed to update the history upon admission. This information was reviewed with facility staff during the licensing process.
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Plan of Correction
New intake materials, including all histories and consents will be utilized for all clients, including returning clients. No client charts are to be reused for any subsequent admissions.
Invalid drug and alcohol history dated 4/1/16 was updated by client #1 and his primary counselor this document was signed and dated 2/27/17.
The Project Director will ensure compliance with this policy by regularly reviewing client charts. |
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 client records on February 24, 2017, the facility failed to document that the treatment and rehabilitation plan was updated every 30 days in client records #2, 4 and 5. Client #2 was admitted on 1/9/17 and was an active client at the time of the inspection. The comprehensive treatment plan was documented on 1/10/17. A treatment plan update was due by 2/10/17 but was not documented at the time of the inspection.Client #5 was admitted on 11/9/16 and was discharged on 1/4/17. The comprehensive treatment plan was documented on 11/10/16. A treatment plan update was due by 12/10/16 but was not documented at the time of the inspection.Client #4 was admitted on 10/10/16 and was discharged on 1/30/17. A treatment plan update was documented on 12/4/16. Another treatment plan update was due by 1/4/17 but was not documented until 1/11/17. This information was reviewed with facility staff during the licensing process.
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Plan of Correction
In accordance with facility policy, all clients receive a treatment plan review every thirty days.
Regarding client #2, a treatment plan review was completed on 2/27/17. A note was included that this review was due on 2/10/17 and that the next review will be conducted on 3/10/17.
To ensure compliance, the Project Director will regularly review client charts.
All counseling staff were briefed on the importance of our monthly treatment plan policy as well as current regulations concerning these reviews. |
709.53(b) LICENSURE Standardized Forms
709.53. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
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Observations
Based on a review of client records on February 24, 2017, the facility failed to utilize standardized forms in client records, #1, 4, and 5.Client #1 was admitted on 12/22/16 and was an active client at the time of the inspection. Two consents to outside agencies, dated 12/27/16, contained text copy on the template that was too faint to be legible. Client #4 was admitted on 11/9/16 and discharged on 1/4/17. A consent to an outside agency, dated 11/10/16, contained text copy on the template that was too faint to be legible. Client #5 was admitted on 10/10/16 and discharged on 1/30/17. A consent to an outside agency, dated 12/1/16, contained text copy on the template that was too faint to be legible. This information was reviewed with the facility staff during the licensing inspection.
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Plan of Correction
All staff members were briefed on proper documentation procedures including ensuring that all documents in clients' charts are legible. Counselors were instructed to notify the office manager if ink levels in the printers are too low to produce legible copies.
The Project Director will regularly review clients' charts to ensure proper documentation procedures are followed including legibility of documents.
The Project Director removed and destroyed all offending documents from the records of clients'#4 and #5.
As for client #1,who was active at the time of the inspection, the two illegible consents identified were replaced by the client's primary counselor. They were signed and dated 2/27/17 by client #1 as well as his primary counselor. |