INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on September 25, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated on-site inspection, Sojourner House 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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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
The facility failed to report an event at the facility requiring the presence of an ambulance.
The unusual incident reports were reviewed during an onsite inspection on September 25, 2020. On August 4, 2020, an event occurred at the facility which required an ambulance. There was no documentation that the facility notified DDAP within 3 business days.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Sojourner House's Program Director created a bulletin board in the staff area with step by step instructions on how to complete and when to complete a DDAP Incident Report.
Program Director, Clinical Supervisor, and Program Manager met with all Sojourner House staff to discuss the importance of completing the incident documentation. Leadership and Managers stressed to staff the importance of printing out a copy of the report when it is completed, and put into the binder that was created to hold all incident reports.
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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
The facility failed to document a physical examination as part of the intake process in three of seven client records.
Seven client records were reviewed onsite on September 25, 2020. All seven records reviewed required the documentation of a physical examination as part of the intake process. Client records #1, 2 and 3 did not include documentation of a physical examination as part of the intake process.
Client #1 was admitted on April 14, 2020. The physical examination was completed on June 8, 2020.
Client #2 was admitted on August 17, 2020. There was no documentation of a physical examination in client record #2.
Client #3 was admitted on July 13, 2020. There was no documentation of a physical examination in client record #3.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Sojourner House's Program Director and Clinical Supervisor met with the Therapist to remind them of the importance of receiving the physical examination in the first week the client is admitted. Moving forward, Sojourner House Clinical Supervisor will review all charts after the assessment is completed between the Therapist and the Client. Also, there was an intake checklist created for the therapist to refer to during the intake process. |