INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on November 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, 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:
|
Plan of Correction
|
704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
|
Observations
Based on a review of the project ' s policy and procedure manual, the project failed to develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. The manual only included the sentence that every effort shall be made to hire staff persons representative of that population.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Project Director has performed a review of Sanctuary House Policy and Procedure in accordance with this deficiency. Project Director has updated Sanctuary House internal policy number 8.1 (Recruitment and Hiring of Staff) to ensure hiring practices are in full compliance with Code 704.3(b) and that it requires staff persons hired to be appropriate to the population being served.
This deficiency has already been corrected, effective immediately.
Sanctuary House has hired a new Project Director as of December 1, 2021 that will be responsible for reviewing all current policy and procedure on an annual basis to ensure compliance with all applicable Department codes and regulations.
|
704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
|
Observations
Based on a review of one personnel record, the facility failed to ensure that the project director and facility director met the qualifications for the position.
Employee #1 was hired as the project director and facility director on January 1, 2021 and was current in that position at the time of the inspection. Employee #1 does not have a qualifying degree or the four years of experience in a human service field required.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Sanctuary House has released Employee #1 from employment as Project Director effective December 1, 2021.
Sanctuary House has hired a new Project Director/Facility Director (PD/FD) effective December 1, 2021. This individual meets all requirements for the position under code 704.5(c). This individual's resume and license were submitted to the Department along with the necessary forms to effect the change to this individual as the PD/FD. Sanctuary House received correspondence from DDAP approving the change on December 15, 2021.
This deficiency is corrected as of DDAP's approval on December 15, 2021.
The CFO/Administrator for Sanctuary House, in conjunction with the Project Director, will oversee and ensure all prospective new hires that are being considered for employment meet any necessary qualification requirements for the position as indicated in PA Code 704 and as provided for in any applicable licensing alerts from the Department. |
705.9 (4) (i) 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:
(i) The evacuation and transfer of residents and staff to a safe location.
|
Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to provide written procedures for staff and residents to follow in case of an emergency including provisions for the evacuation and transfer of residents and staff to a safe location.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director has performed a review of Sanctuary House Policy and Procedure in accordance with this deficiency. Project Director has updated Sanctuary House internal policy number 7.1 (Evacuation and Transfer Policy) to include additional procedures for staff to follow in the event of an emergency, inclusive of specific information regarding the evacuation and transfer of clients and staff to a safe location.
This deficiency has already been corrected via policy update on 12/15/21.
Sanctuary House has hired a new Project Director as of December 1, 2021 that will be responsible for reviewing all current policy and procedure on an annual basis to ensure compliance with all applicable Department codes and regulations. |
705.9 (4) (ii) 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:
(ii) Assignments of staff during emergencies.
|
Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to provide written procedures for staff and residents to follow in case of an emergency including provisions for the assignments of staff during emergencies.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director has performed a review of Sanctuary House Policy and Procedure in accordance with this deficiency. Project Director has updated Sanctuary House internal policy number 7.1 (Evacuation and Transfer Policy) to include additional procedures for staff to follow in the event of an emergency, inclusive of staff assignments during emergencies.
This deficiency has already been corrected via policy update on 12/15/21.
Sanctuary House has hired a new Project Director as of December 1, 2021 that will be responsible for reviewing all current policy and procedure on an annual basis to ensure compliance with all applicable Department codes and regulations. |
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.
|
Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to provide written procedures for staff and residents to follow in case of an emergency including provisions for the evacuation and transfer of residents impaired by alcohol or other drugs.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director has performed a review of Sanctuary House Policy and Procedure in accordance with this deficiency. Project Director has updated Sanctuary House internal policy number 7.1 (Evacuation and Transfer Policy) to include additional procedures for staff to follow for the evacuation and transfer of clients impaired by alcohol or other drugs.
This deficiency has already been corrected via policy update on 12/15/21.
Sanctuary House has hired a new Project Director as of December 1, 2021 that will be responsible for reviewing all current policy and procedure on an annual basis to ensure compliance with all applicable Department codes and regulations. |
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.
|
Observations
Based on the review of one personnel file and the Staffing Requirement Facility Summary Report (SRFSR), the facility failed to instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility. Three of three staff listed on the SRFSR had not been instructed in the use of the fire extinguishers upon staff employment.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Sanctuary House has implemented a revised new employee orientation checklist that includes documenting the instruction of handling fire extinguishers by new employees.
The CFO/Administrator will be responsible for overseeing the orientation of new employees and the utilization of this checklist to ensure all required orientation tasks for new employees, inclusive of fire extinguisher training, are completed and documented accordingly in each respective personnel file.
Current employees have received or are scheduled to receive this training during the month of January 2022.
This deficiency will be corrected in full by January 31, 2022. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a discussion with facility staff, the facility failed to conduct any unannounced fire drills since opening in January 2021.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Sanctuary House has implemented the practice of unannounced fire drills being conducted on a monthly basis. The Project Director will be responsible for ensuring that unannounced fire drills are conducted and documented at least once per month and that this deficiency does not reoccur.
The new Project Director, hired December 1, 2021, has implemented this practice and documentation effective for the month of January 2022.
This deficiency will be corrected by January 31, 2022. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on the review of one personnel file and the Staffing Requirement Facility Summary Report (SRFSR), the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies for all three personnel listed on the SRFSR.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Sanctuary House has implemented a revised new employee orientation checklist that includes documenting the instruction of staff in conducting fire drills and assignments/tasks during emergency situations.
Further, Sanctuary House has updated its Evacuation and Transfer Policy to provide specific detail as to staff assignments during emergencies. This poilcy and procedure update will be covered with new employees during their orientation.
The CFO/Administrator will be responsible for overseeing the orientation of new employees and the utilization of this checklist to ensure all required orientation tasks for new employees, inclusive of conducting fire drills and assigned tasks during an emergency, are completed and documented accordingly in each respective personnel file.
Previous employees have been or will be trained accordingly with documentation placed into their personnel files by end of January 2022.
This deficiency will be corrected by January 31, 2022. |
709.24 (b) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(b) The project shall maintain a current community resource listing of other health and social service agencies.
|
Observations
Based on a physical plant inspection and review of the project ' s policy and procedure manual the project failed to maintain a current community resource listing of other health and social service agencies.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Project Director has performed a review of Sanctuary House policy and procedure manual and updated internal policy 6.2 (Ancillary Services) to include a list of current community resources for other health and social service agencies.
This updated resource list will be provided to staff to make use of as needed.
The Project Director will be responsible for making revisions and updates to this list as necessary and will review it for accuracy at least once annually during Policy and Procedure review.
This deficiency is corrected, effective 1/3/22. |
709.26 (a) LICENSURE Personnel Management
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
|
Observations
Based on an on-site annual licensing inspection on November 22, 2021 and interviews with the governing body, the facility created written personnel policies and procedures but did not implement them. The facility was licensed in January 2021 by the Department of Drug and Alcohol Programs as a transitional living facility, but they continued to operate as housing for sober living residents. The facility did not implement the transitional living facility regulatory requirements prior to the on-site inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Sanctuary House has implemented the utilization of its full policies and procedures as a licensed Transitional Living Facility effective January 3, 2022.
The CEO, CFO/Administrator, and Project Director will collectively oversee the progress of this implementation and ensure that all policies and procedures are followed in accordance with being a licensed Transitional Living Facility and not a Sober Living Residence moving forward.
The deficiency will be fully corrected by January 31, 2022. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
|
Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop written policies and procedures that included the utilization of volunteers.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director has amended the Policy and Procedure manual to include a new policy with internal number 8.7, titled, "Utilization of Volunteers." The Sanctuary House does not utilize volunteers and now accurately reflects this practice in its written policy.
This deficiency is corrected by policy and procedure update on 1/3/2022.
Sanctuary House has hired a new Project Director as of December 1, 2021 that will be responsible for reviewing all current policy and procedure on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.26 (b) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(1) Application or resume for employment.
|
Observations
Based on a review of the facility ' s Staffing Requirement Facility Summary Report (SRFSR), the facility failed to develop personnel records that included an application or resume for employment for the Administrator and House Manager. The facility had not developed any personnel records prior to the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Sanctuary House has implemented a personnel file checkoff list that will ensure each personnel file will have all necessary pieces of information within it, inclusive of a resume and/or application for employment.
The CFO/Administrator will be responsible for overseeing the implementation and utilization of this checklist to ensure this deficiency does not reoccur.
This deficiency is corrected, effective immediately. |
709.26 (b) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(2) Written verification of qualifying professional credentials.
|
Observations
Based on a review of the facility ' s Staffing Requirement Facility Summary Report (SRFSR) and discussion with the governing body, the facility failed to develop personnel records that included written verification of qualifying professional credentials. The facility did not have a personnel record that included written verification of qualifying professional credentials for the project director/facility director.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Sanctuary House has implemented a personnel file checkoff list that will ensure each personnel file will have all necessary pieces of information within it, inclusive of a written verification of qualifying professional credentials.
The CFO/Administrator will be responsible for overseeing the implementation and utilization of this checklist to ensure this deficiency does not reoccur.
This deficiency is corrected, effective immediately. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
|
Observations
Based on an on-site annual licensing inspection on November 22, 2021 and discussions with the governing body, the facility developed written policies and procedures on client rights but had not implemented them. The facility was licensed in January 2021 by the Department of Drug and Alcohol Programs as a transitional living facility, but they continued housing sober living clients and did not document written acknowledgement by clients that they have been notified of those client rights.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Sanctuary House hired a new Project Director on December 1, 2021 to oversee the implementation of policies, procedures and documentation for all clients living in the facility that were previously being regarded as "sober living clients."
As such, a complete and accurate client record is being developed for each client at The Sanctuary House, inclusive of documentation of the written acknowledgement of each client's notification of The Sanctuary House Client Rights.
This deficiency is in process of being corrected with current clients and will be completely resolved by January 31, 2022.
Project Director will be responsible for reviewing all current policy and procedure, and ensuring its active implementation, on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to an event at the facility requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director has performed a review of Sanctuary House Policy and Procedure in accordance with this deficiency. Project Director has amended Sanctuary House internal policy number 5.1 (Reporting, Recording and Investigating Unusual Incidents) to include reporting of events at facility that require presense of police, fire, and/or ambulance personnel.
This deficiency has already been corrected, effective immediately.
Sanctuary House has hired a new Project Director as of December 1, 2021 that will be responsible for reviewing all current policy and procedure on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.34 (a) (7) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(7) Fire or structural damage to the facility.
|
Observations
Based on a review of the facility ' s policy and procedure manual, the facility failed to develop and implement policies and procedures to respond to fire or structural damage to the facility.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director has performed a review of Sanctuary House Policy and Procedure in accordance with this deficiency. Project Director has amended Sanctuary House internal policy number 5.1 (Reporting, Recording and Investigating Unusual Incidents) to include reporting of events that cause fire or structural damage to the facility.
This deficiency has already been corrected, effective immediately.
Sanctuary House has hired a new Project Director as of December 1, 2021 that will be responsible for reviewing all current policy and procedure on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.71(a)(2) LICENSURE Completion Guidelines
709.71. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(2) Guidelines for completion of residency.
|
Observations
Based on a review of the facility ' s written plan for intake and admission, the facility failed to develop guidelines for completion of residency. The written plan identifies rules and guidelines to follow in the facility, however no guidelines are identified for completing residency.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director has amended the Policy and Procedure manual to include a new policy with internal number 9.1, titled, "Criteria for Successful Completion." The Sanctuary House now has policy in place that clearly defines the minimum requirements for completion of residency.
This deficiency is corrected by policy and procedure update on 1/3/2022.
Sanctuary House has hired a new Project Director as of December 1, 2021 that will be responsible for reviewing all current policy and procedure on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.7(b)(2)(ii) LICENSURE Orientation/operation hours
709.71. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but not be limited to a familiarization with:
(ii) Hours of operation.
|
Observations
Based on an on-site annual licensing inspection on November 22, 2021 and discussions with the governing body, the facility was licensed in January 2021 by the Department of Drug and Alcohol Programs as a transitional living facility, but they continued housing sober living clients. The facility failed to have intake procedures that included documentation of a client orientation to the project which included familiarization with the hours of operation.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director has amended the Policy and Procedure manual to include a new policy with internal number 9.2, titled, "Hours of Operation and Client Orientation." The Sanctuary House now has policy in place that clearly defines the hours of operation, the visible display of those hours, and the procedure for performing the documented orientation of each client to those hours of operation.
This deficiency is corrected by policy and procedure update on 1/3/2022.
Sanctuary House has hired a new Project Director as of December 1, 2021 that will be responsible for reviewing all current policy and procedure on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.71(b)(2)(iii) LICENSURE Orientation/Fee Schedule
709.71. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but not be limited to a familiarization with:
(iii) Fee schedule.
|
Observations
Based on an on-site annual licensing inspection on November 22, 2021 and discussions with the governing body, the facility was licensed in January 2021 by the Department of Drug and Alcohol Programs as a transitional living facility, but they continued housing sober living clients. The facility failed to have intake procedures that included documentation of a client orientation to the project which included familiarization with the fee schedule.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director has amended the Policy and Procedure manual to include a new policy with internal number 9.3, titled, "Fee Schedule." The Sanctuary House now has policy in place that clearly defines the per diem fee schedule for clients in the Transitional Living Facility project and provides procedure to ensure that each client is oriented to this fee schedule as part of the Admission and Intake process, and such is documented accordingly.
This deficiency is corrected by policy and procedure update on 1/3/2022.
Sanctuary House has hired a new Project Director as of December 1, 2021 that will be responsible for reviewing all current policy and procedure on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.71(b)(2)(iv) LICENSURE Orientation/Services provided
709.71. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which shall include, but not be limited to a familiarization with:
(iv) Services provided.
|
Observations
Based on an on-site annual licensing inspection on November 22, 2021 and discussions with the governing body, the facility was licensed in January 2021 by the Department of Drug and Alcohol Programs as a transitional living facility, but they continued housing sober living clients. The facility failed to have intake procedures that included documentation of a client orientation to the project which included familiarization with the services provided.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Project Director has amended the Policy and Procedure manual to include a new policy with internal number 9.4, titled, "Services Provided." The Sanctuary House now has policy in place that clearly defines the Services provided to clients in the Transitional Living Facility project and provides procedure to ensure that each client is oriented to these services as part of the Admission and Intake process, and such is documented accordingly.
This deficiency is corrected by policy and procedure update on 1/3/2022.
Sanctuary House has hired a new Project Director as of December 1, 2021 that will be responsible for reviewing all current policy and procedure on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.71(b)(3) LICENSURE Basic Personal data
709.71. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Basic personal data.
|
Observations
Based on an on-site annual licensing inspection on November 22, 2021 and discussions with the governing body, the facility was licensed in January 2021 by the Department of Drug and Alcohol Programs as a transitional living facility, but they continued housing sober living clients. The facility failed to have intake procedures that included documentation of basic personal data.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Sanctuary House hired a new Project Director on December 1, 2021 to oversee the implementation of policies, procedures and documentation for all clients living in the facility that were previously being regarded as "sober living clients."
As such, a complete and accurate client record is being developed for each client that is presently at The Sanctuary House, inclusive of documentation of each client's basic personal data.
This deficiency is in process of being corrected with current clients and will be completely resolved by January 31, 2022.
Project Director will be responsible for reviewing all current policy and procedure, and ensuring its active implementation, on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.71(b)(4) LICENSURE Consent to Residency
709.71. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to residency.
|
Observations
Based on an on-site annual licensing inspection on November 22, 2021 and discussions with the governing body, the facility was licensed in January 2021 by the Department of Drug and Alcohol Programs as a transitional living facility, but they continued housing sober living clients. The facility failed to have intake procedures that included documentation of consent to residency.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Sanctuary House hired a new Project Director on December 1, 2021 to oversee the implementation of policies, procedures and documentation for all clients living in the facility that were previously being regarded as "sober living clients."
As such, a complete and accurate client record is being developed for new and existing clients of The Sanctuary House, inclusive of documentation of each client's signed consent to residency at the project.
This deficiency is in process of being corrected with current clients and will be completely resolved by January 31, 2022.
Project Director will be responsible for reviewing all current policy and procedure, and ensuring its active implementation, on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.72(a) LICENSURE Individual client record
709.72. 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:
|
Observations
Based on an on-site annual licensing inspection on November 22, 2021 and discussions with the governing body, the facility was licensed in January 2021 by the Department of Drug and Alcohol Programs as a transitional living facility, but they continued housing sober living clients. The facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Sanctuary House hired a new Project Director on December 1, 2021 to oversee the implementation of policies, procedures and documentation for all clients living in the facility that were previously being regarded as "sober living clients."
As such, a complete and accurate client record is being developed for each client that is presently at The Sanctuary House, inclusive of information relavant to client's involvement with the project from deployment of records moving forward.
This deficiency is in process of being corrected with current clients and will be completely resolved by January 31, 2022.
Project Director will be responsible for reviewing all current policy and procedure, and ensuring its active implementation, on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.72(a)(1) LICENSURE Consent Forms
709.72. 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:
(1) Consent forms.
|
Observations
Based on an on-site annual licensing inspection on November 22, 2021 and discussions with the governing body, the facility was licensed in January 2021 by the Department of Drug and Alcohol Programs as a transitional living facility, but they continued housing sober living clients. The facility failed to have a complete client record on an individual which includes information relative to the client's involvement with the project, including, but not limited to consent forms.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Sanctuary House hired a new Project Director on December 1, 2021 to oversee the implementation of policies, procedures and documentation for all clients living in the facility that were previously being regarded as "sober living clients."
As such, a complete and accurate client record is being developed for each client that is presently at The Sanctuary House, inclusive of any and all necessary signed consent forms required to facilitate services or communication on client's behalf.
This deficiency is in process of being corrected with current clients and will be completely resolved by January 31, 2022.
Project Director will be responsible for reviewing all current policy and procedure, and ensuring its active implementation, on an annual basis to ensure compliance with all applicable Department codes and regulations. |
709.72(b) LICENSURE Standardized client records
709.72. Client records.
(b) The project shall develop and maintain client records on standardized project client record forms.
|
Observations
Based on interviews and a physical plant inspection conducted on November 22,2021, it was confirmed that six individuals were residing at the transitional living facility. Interviews confirmed the facility was operating as a sober living residence instead of a licensed transitional living facility. There were no transitional living facility services being offered, and there were no client records being maintained.
The Sanctuary House, LLC is a licensed transitional living facility and any individual residing there is a client. The facility failed to document complete client records on the clients residing in the transitional living facility.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Sanctuary House hired a new Project Director on December 1, 2021 to oversee the implementation of policies, procedures and documentation for all clients living in the facility that were previously being regarded as "sober living clients."
As such, a complete and accurate client record is being developed for each client that is presently at The Sanctuary House.
This deficiency is in process of being corrected with current clients and will be completely resolved by January 31, 2022.
Project Director will be responsible for reviewing all current policy and procedure, and ensuring its active implementation, on an annual basis to ensure compliance with all applicable Department codes and regulations. |