INITIAL COMMENTS
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This report is a result of an on-site licensure renewal conducted on February 12, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of 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. The following deficiencies were identified during this inspection:
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Plan of Correction
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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 staff records, the facility failed to ensure staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics within the first year of employment in one of one applicable record.
Staff #2 was hired to the position of counselor on July 24, 2023 and was promoted to the position of clinical supervisor on November 1, 2024. Staff #2 was due to complete 6 hours of HIV/AIDS training and 4 hours of TB/STD training no later than July 24, 2024. However, staff #2 did not complete 6 hours of HIV/AIDS training and 4 hours of TB/STD as of the date of review.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
All current staff will be retrained in HIV/AIDS with the requirement of 6 hours of training. All staff will also receive 4 hours of TB/STD/and other health related topics training. All trainings will be approved by DDAP or follow approved requirements.
Clinical Supervisor and Administrative Assistant will monitor the training plans for all new employees to ensure compliance with training regulations.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of facility records, the facility failed to have and implement a written policy and procedure regarding medications used by clients which includes methods for control and accountability of drugs, including the programs system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 7, 2024 annual licensing inspection.
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Plan of Correction
Executive Director has updated the medication control policy to reflect the DDAP regulations and the citation.
Harbor Light Center utilizes a MAR as the system for recording drugs. Each MAR will include the name of the client, the name of the drug, route of administration, how often the drug is to be taken, and dosage of the drug. The MAR will also include the medication time to be taken, the date the drug was taken by the client, and then the staff member will provide their initials to signify that the medication was witnessed as taken by the client.
The Healthcare Navigator will review the MARs provided by the partner pharmacy prior to their use at the beginning of each month. HCN will review for errors, inconsistencies, and report these to Director and pharmacy immediately for correction.
HCN will then review the MARs at the end of each week to review staff compliance of the MAR recording guidelines. All deficiencies will be reported to the Director. Director will then review these deficiencies, discuss with appropriate staff to make corrections or provide more medication training if necessary.
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709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of facility records, the facility failed to have and implement a written policy and procedure regarding medications used by clients which includes medication errors and drug reactions shall be recorded in the client record.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 7, 2024 annual licensing inspection.
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Plan of Correction
Executive Director has updated the medication control policy to reflect the DDAP regulations and the citation.
When a client misses a medication for any reason or has reaction to medication it will be noted in an individual note written by the therapist or Healthcare Navigator. The Healthcare Navigator will also contact the prescriber to inform them of missed doses or reactions and seek additional information or what to do next.
Healthcare Navigator will provide Director with a monthly reconciliation of any medication errors, missed medications, drug reactions, etc. Director will review with appropriate staff, clients, prescribing physicians, etc. if further direction or action is needed. |
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, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in five of six applicable records.
Client #3 was admitted to the inpatient level of care on August 27, 2024 and was discharged January 9, 2025. Client #3 ' s record contained a treatment plan dated October 11, 2024. A treatment plan update was due no later than November 11, 2024. The next treatment plan update for Client #3 was completed December 13, 2024.
Client #4 was admitted to the inpatient level of care on August 19, 2024 and was discharged January 20, 2025. Client #4 ' s record contained a treatment plan dated November 27, 2024. A treatment plan update was due no later than December 27, 2024. The next treatment plan update for Client #4 was completed December 31, 2024.
Client #5 was admitted to the inpatient level of care on November 12, 2024 and was active at the time of review. Client #5 ' s record contained a treatment plan dated December 25, 2024. A treatment plan update was due no later than January 25, 2025. The next treatment plan update for Client #5 was completed January 29, 2025.
Client #6 was admitted to the inpatient level of care on November 20, 2024 and was active at the time of review. Client #6 ' s record contained a treatment plan dated December 31, 2024. A treatment plan update was due no later than January 31, 2025. The next treatment plan update for Client #6 was completed February 3, 2025.
Client #7 was admitted to the inpatient level of care on November 6, 2024 and was active at the time of review. Client #7 ' s record contained a treatment plan dated December 18, 2024. A treatment plan update was due no later than January 18, 2025. The next treatment plan update for Client #7 was completed January 22, 2025.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 7, 2024 annual licensing inspection.
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Plan of Correction
Therapists will complete their treatment plan updates and have the plan signed prior to the due date. Therapists will collaborate with clients to make updates, goals, action steps, etc. before the treatment plan is due to ensure that it gets completed and signed by both parties within the allotted timeframe. Clinical Supervisor will continue to provide therapists with a list of what documents are due for the coming week; supervisor will also continue to monitor document compliance weekly. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to ensure there was a complete client record that includes follow-up information in four of four applicable records.
Facility policy and procedure states that follow-up contact is made within seven days of discharge.
Client #1 was admitted to the inpatient level of care on November 13, 2024 and was discharged December 13, 2024. Client #1 ' s record did not contain any follow-up information.
Client #2 was admitted to the inpatient level of care on August 5, 2024 and was discharged October 26, 2024. Client #2 ' s record did not contain any follow-up information.
Client #3 was admitted to the inpatient level of care on August 27, 2024 and was discharged January 9, 2025. Client #3 ' s record did not contain any follow-up information.
Client #4 was admitted to the inpatient level of care on August 19, 2024 and was discharged January 20, 2025. Client #4 ' s record did not contain any follow-up information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Recovery Support Specialist will be tasked with completing client follow ups within their time frame. The Recovery Support Specialist will complete the 7 day follow up form for all clients discharged from The Harbor Light Center. These forms will be placed within a binder labeled for all client follow ups. Clinical Supervisor and Executive Director will monitor for compliance monthly and follow up with Recovery Support Specialist as needed. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to provide verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan, in seven of seven applicable records.
There was no documentation on any treatment plan that work done by the client while in residential treatment was an integral part of treatment in all records reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor has reminded all therapists that work therapy has to be incorporated in to all client's treatment plans who will be participating in work therapy. Clinical Supervisor will monitor all initial comprehensive treatment plans for compliance during weekly documentation reviews. Treatment plan updates or revisions will be made as needed. |