INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 22, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Salvation Army Harbor Light Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document 25 clock hours of annual training in one of one personnel record reviewed.
The findings include:
Four personnel records were reviewed on March 22, 2016. One out of four personnel records pertained to a counselor and was reviewed for annual training hours. The facility's training year is from January through December. The facility failed to document 25 clock hours of annual training for employee #2 for the January 1, 2015 - December, 2015 training year.
Employee # 2, a counselor, was hired in November of 2012. Employee record #2 contained documentation of 14.5 clock hours of annual training for the January 1, 2015 - June 30, 2015 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A supervisor will review with employee 2 and all other staff the licensing requirements for training hours. A training log will be developed which will track all trainings and training hours in a calendar year for each individual staff person. The staff (ex. Employee 2) will be responsible for registering, completing and documenting the required number of trainings hours. This process will be observed weekly by the clinical supervisor to determine that the staff are meeting these requirements and aiding the staff, as needing, with training registration and documentation. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection, the facility failed to keep the grounds clean, safe, and sanitary and in good repair at all times for the safety and well-being of clients, employees and visitors.
The findings include:
A physical plant inspection was conducted on March 22, 2016. The furniture was not in good repair as tape was observed on some of the couches and chairs throughout the recreational area.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility director and the building maintenance staff will have a company reupholster all the couch and chair cushions for the recreation room furniture. Per the Salvation Armys protocol, 2-3 bids for repair will be found, the bids will then go to The Salvation Army financial committee for approval. Once approved, we will go ahead with the upholstering. Any furniture that may be broken beyond repair will be discarded by the facility director. |
705.6 (1) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(1) Provide bathrooms to accommodate staff, residents and other users of the facility.
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Observations
Based on the observation which occurred during the physical plant inspection, the facility failed to provide privacy in toilets by doors and failed to provide slip-resistant surfaces in all showers.
The findings include:
The physical plant inspection took place on March 22, 2016 at around 10 am. The facility failed to ensure that the staff male restroom stall, located on the first floor by the entrance, had a door that provided privacy. Additionally, the facility failed to ensure that slip resistant surfaces were provided for all the showers located on the second floor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A plumbing company will be hired by the facility to replace the existing toilet partition so that the gap that was observed will be minimized to ensure privacy.
Slip resistance material will be purchased and installed by the facility to meet slip resistant requirements in the second floor shower room.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during a physical plant inspection, the facility failed to ensure that there were no heaters located within the facility that were not permanently mounted or installed.
The findings include:
A physical plant inspection was conducted on March 22, 2016 at approximately 10:00 AM.
A portable space heater that was not permanently mounted or installed was observed in the counselor's office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The space heater that was observed during the inspection has been removed from the office. The facility director will also meet with all staff to remind them of the requirement that no portable space heaters are allowed in the facility. Management will also periodically observe offices to make sure that this requirements has been followed. |
709.1(b) LICENSURE Subchapter A.General Provisions.Scope
709.1. Scope
(b) This chapter provides standards by activity for the licensure of free-standing drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P.S. Sections 901-922, 1001-1031, and 1051-1059).
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Observations
Based on a physical plant inspection, the facility failed to comply with the maximum approved capacity.
The findings include:
A physical plant inspection was conducted on March 22, 2016.
The facility is licensed by the Division for a maximum client capacity of 40 inpatient non-hospital drug-free beds. The facility exceeded the licensed maximum capacity as there were 42 non-hospital drug-free beds in the facility at the time of inspection.
The findings were reviewed with facility staff during the complaint investigation.
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Plan of Correction
Two beds will be removed from the living quarters by the facility director so that maximum capacity for the building meets 40 bed licensing requirements. Once the beds have been removed, the facility director will complete another count of beds and will do this periodically through the year to make sure count stays at 40 beds. |