This report is a result of an on-site provisional license follow-up inspection conducted on March 9, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Sanctuary House, LLC 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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Observations
Based on an unannounced provisional follow-up onsite inspection on March 9, 2022, and email requests for information, the facility failed to develop a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
An email was sent on March 2, 2022, requesting the Staffing Requirements Facility Summary Report, Data Collection Report, and the Emergency Contact policy, however as of March 10, 2022, the information was not received.
An email was also sent on March 7, 2022, requesting the staff schedule and CPR cards, however as of March 10, 2022, the information was not received.
An email was sent the morning of March 9, 2022, to inform the facility that a provisional follow up inspection would be occurring that day. Additionally, the email requested a list of discharged clients, fire drill records, access to client and personnel records along with the previously requested information be accessible that day. Upon arrival to the facility, at approximately 10:45am, staff at the facility did not have access to any of the requested information.
These findings were reviewed with the facility during the inspection process.
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Plan of Correction
The Sanctuary House utilizes a paper-based data collection and record keeping system. These records are contained in properly labeled file folders contained in a file storage unit at the facility. These files may be easily accessed and reviewed to measure performance of project goals and objectives.
On March 11, 2022, The Project Director submitted the Staffing Requirements Facility Summary report, Data Collection Report, Emergency Contact Policy, and CPR cards directly to inspector via reply email.
The requested staffing schedule was not provided as there are presently no staff scheduled due to there being no clients in residency since February 1, 2022.
The Project Director has returned to the facility all of the personnel, client records, discharged client list, and fire drill records in a secured, locked file container, located in a locked facility office.
The deficiencies listed have been corrected and resolved, effective immediately.
The Project Director will be responsible to ensure that all project records are always kept in the facility, regardless of project operating status, and that they are readily accessible to Department inspection upon request. |