INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 9, 2023 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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704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to supervise the counselor assistant by a full-time clinical supervisor or counselor who meets the qualifications. The facility employs one counselor assistant and a clinical supervisor who is also the Facility Director and Project Director.
Employee #1 was hired on December 21, 2021 as the Project Director, Facility Director, and Clinical Supervisor.
Employee #2 was hired on January 1, 2021 as a residential tech and then was promoted on June 15, 2023 as a counselor assistant.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director has reviewed the staffing requirements facility summary report submitted along with the personnel file for employee #1. Additionally, the project director has completed a review of the staffing requirements for the positions of clinical supervisor and counselor as outlined in PA Code 704. Based on that review, employee #1 meets all the qualifications for both the position of clinical supervisor and/or counselor, presently works in a full-time capacity, and serves as the counselor for all the clients.
The project director, in conjunction with the governing body, effective immediately, has submitted an exception request for 704.9(a) to the Department to allow for the project director, who serves and addresses the clinical needs of the project, to be permitted to also provide the supervision of a counselor assistant.
The project will not allow the counselor assistant to provide clinical services until such time as this exception is granted.
Further, if the department does not grant this exception, the counselor assistant will not be permitted to provide clinical services, and will be relocated to patient technician duties.
This deficiency is corrected effective immediately with further action based on the request for exception response from the department. |
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 personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #2 was hired as a residential tech on January 1, 2021 and was due to have the communicable disease trainings no later than January 1, 2023. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director has reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedure and the personal file of employee #2. His HIV/AIDS training was completed on 8/4/23 (HIV) This part of the issue was corrected on 8/4/23. Employee #2 is currently waiting for a spot in the TB Training course. This issue will be corrected as soon as possible with a target date no later than 12/31/2023, based on availability of training slots. Furthermore, the project director will perform a quarterly review of all personal files to ensure training requirements compliance. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that at least one person trained in CPR and first aid is onsite during project ' s working hours.
Employee #3 was hired on July 26, 2023 as a residential tech and was still in the position as of the time of the inspection. He does not have first aid training and was alone onsite on July 23, July 24, July 26, and July 28, 2023.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director has reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedure and the personal file of employee #3. Employee #3 completed part 1 of his Adult First Aid/CPR/AED Training on 8/9/23. Employee #3 is scheduled for the skills portion, part 2, within 90 days by 11/9/2023. This issue will be fully resolved by 11/10/2023.
Additionally, the new staff orientation list has been updated to ensure that employees have a valid CPR and First Aid certificate prior to their actual start date. This will now be part of the hiring procedure. The administrator will be responsible for confirming this for all new hires. Further, the project director will review all staff scheduling to ensure there is always at least one staff member with the required CPR/first Aid Training on site.
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705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group and individual counseling rooms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director has reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedure. The camera in the group/counseling room has been removed. A camera will remain in the med office, but counseling will not be done in that area. This issue is resolved, effective immediately. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection, the facility failed to maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. Neither the attic nor the basement had a fire extinguisher.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The project director has reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedure. On 8/29/2023, the administrator purchased and installed 2 fire extinguishers with an ABC rating in the attic and basement. The project director has confirmed the installation of these extinguishers. This issue is resolved, effective immediately. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill logs from September 30, 2022 through July 31, 2023 the facility failed to conduct a fire drill during sleeping hours at least every 6 months. A fire drill during sleeping hours was completed on December 31, 2022 and not again as of the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director has reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedure. An overnight fire drill was conducted on 8/24/23 at 1 am. The project director and CA will schedule an additional overnight (sleeping hours) fire drill at least every 6 months. This issue is corrected, effective immediately. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to complete an annual written individual staff performance evaluation, a copy of which shall be reviewed and signed by the employee.
Employee #1 was hired as the Project Director on December 1, 2021 and was still employed at the time of the inspection. An annual written performance evaluation was completed on January 4, 2023; however, it was not signed by the employee.
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Plan of Correction
The project director has reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedure and the personal file of employee #1. The evaluation is now signed. This issue was immediately corrected. Additionally, there is now a performance evaluation form with signature lines that will be completed for every employee when required. The project director will complete a quarterly review of personnel files to ensure these are complete and correct. |
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.
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Observations
Based on a review of facility records, the facility failed to inform the Department of unusual incidents within the required three days. It was discovered that the facility had unusual incidents occur on January 15, 2023, February 25, 2023, March 11, 2023, and April 6, 2023 all which involved presence of an ambulance. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director has reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedure. The project director has added a check box on the internal incident report to confirm that an Unusual Incident Report was filed with the Department within 72 hours if there was fire, police, or ambulance contact, as well as any other required reportable incident as indicated in Licensing Alert 02-2018. The project director will be responsible for ensuring ongoing compliance with this regulation. This issue has been corrected effective immediately. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a physical examination in five out of nine records reviewed.
Client #2 was admitted on April 24, 2023 and was still an active client at the time of the inspection.
Client #3 was admitted on April 10, 2023 and was still an active client at the time of the inspection.
Client #5 was admitted on July 7,2023 and was still an active client at the time of the inspection.
Client #6 was admitted on April 21, 2023 and was discharged on June 3, 2023.
Client #9 was admitted on December 7, 2022 and was discharged on April 22, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director has reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedure. This issue has been corrected by adding an internal Preadmission check list that requires a history and Physical be in the client record 2 days prior to admission. CA or Tech supervisor will be responsible for making sure this is in the record and the check list is added to the admission paperwork in the client record. It will also be added to the weekly chart monitoring/case management tasks list that was created by the project director. A designated tech will go over this list weekly and report to the CA and project director any outstanding tasks. This issue is corrected effective immediately. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in six out of nine records reviewed.
Client #1 was admitted on June 5, 2023 and was still active at the time of the inspection.
Client #2 was admitted on April 24, 2023 and was still active at the time of the inspection.
Client #3 was admitted on April 10, 2023 and was still active at the time of the inspection.
Client #6 was admitted on April 21, 2023 and was discharged on June 3, 2023.
Client #7 was admitted on December 6, 2022 and was discharged on April 5, 2023.
Client #9 was admitted on December 7, 2022 and was discharged on April 22, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project director has reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedure as well as client records 1, 2, 3, 6, 7 and 9. A check list of weekly chart monitoring/case management tasks list was created by the project director inclusive of confirming the completion of a psychosocial evaluation. A designated tech will go over this list weekly and report to the CA and project director any outstanding tasks. This issue is resolved, effective immediately. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual or regulatory requirements in seven out of nine records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 14 days following admission.
Client #1 was admitted on June 5, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than June 19, 2023; however, it was not competed until June 20, 2023.
Client #2 was admitted on April 24, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was completed on April 24, 2023; however, it was not signed until August 8, 2023.
Client #3 was admitted on April 10, 2023 and was still active at the time of the inspection. The comprehensive treatment plan was due no later than April 24, 2023; however, it was not completed until April 26, 2023.
Client #6 was admitted on April 21, 2023 and was discharged on June 3, 2023. A comprehensive treatment plan was completed on April 21, 2023; however, it was not signed by the client.
Client #7 was admitted on December 6, 2022 and was discharged on April 5, 2023. A comprehensive treatment plan was completed on December 6, 2022; however, it was not signed by the client.
Client #8 was admitted on April 27, 2023 and was discharged on July 7, 2023. A comprehensive treatment plan was completed on April 27, 2023; however, it was not signed by the client until June 9, 2023.
Client #9 was admitted on December 7, 2022 and was discharged on April 22, 2023. A comprehensive treatment plan was completed on December 7, 2023; however, it was not signed by the client.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The project director has reviewed Regulations, Licensing Alerts and Sanctuary House Policy and Procedure. A weekly chart monitoring/case management tasks list has been created that monitors for treatment plan signatures within the required time frame by the project director A designated tech will go over this list weekly and report to the CA and project director any outstanding signatures. This issue is resolved, effective immediately. |