INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on August 7, 2019. Based on the findings of the on-site inspection, Tradition House was found to not 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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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
The facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times.
During a site inspection on August 7, 2019, the showers in the facility had moldy and mildewed shower curtains.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The bathrooms will continue to be cleaned, sanitized, and maintained daily. Housekeeping will report any areas of concern immediately to Executive Director. All present shower curtains were replaced on 8/8/19 in all bathrooms. |
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.
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Observations
During a review of fire drills on August 7, 2019, the facility failed to conduct unannounced fire drills at least once a month.
There was no fire drill documented for the month of July 2018.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All fire drills will be conducted monthly. Executive Director will review monthly fire drill logs for completion and ensure they meet regulations. Risk Committee will also review records monthly for accuracy of fire drills. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
During a review of facility fire drill from August 2018 through July 2019, the facility failed to prepare alternate exit routes to be used during fire drills.
The facility documented the use of the same exit route for all fire drills for the past year. All fire drills from August 2018 through July 2019 documented use of the back exit only.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed regulations for fire drills with staff on August 26, 2019. Reviewed the need to use alternative routes each month. Program Director will monitor monthly drills to ensure protocol is being followed. |
709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
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Observations
During a Project Wide review of the Policy and Procedures, the project failed to include sex and marital status in the Client Rights policy.709.30 (2), and also the project failed to include documentation of the reasons for removing sections from the record. 709.30 (3).
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual will be updated by the Policy and Procedure committee to include sex and marital status in section 709.30. Chief Compliance Officer will ensure completion of policy by September 1, 2019. The Program Director will be responsible to ensure that the new policy is shared with all staff by September 15,2019. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
During a review of client records on August 7, 2019, the facility failed to notify clients of all their civil rights in seven out of seven records.
Client #1 was admitted on May 16, 2019 and was current at the time of the inspection. Client #1 was not notified that the project may not discriminate on the basis of sex and color.
Client #2 was admitted on May 6, 2019 and was current at the time of the inspection. Client #2 was not notified that the project may not discriminate on the basis of sex and color.
Client #3 was admitted on May 30, 2019 and was current at the time of the inspection. Client #3 was not notified that the project may not discriminate on the basis of sex and color.
Client #4 was admitted on May 6, 2019 and was discharged on August 5, 2019. Client #4 was not notified that the project may not discriminate on the basis of sex and color.
Client #5 was admitted on March 21, 2019 and was discharged on April 18, 2019. Client #5 was not notified that the project may not discriminate on the basis of sex and color.
Client #6 was admitted on April 5, 2019 and was discharged on May 20, 2019. Client #6 was not notified that the project may not discriminate on the basis of sex and color.
Client #7 was admitted on February 8, 2019 and was discharged on July 26, 2019. Client #7 was not notified that the project may not discriminate on the basis of sex and color.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The new form to be added to Carelogic for all programs by September 1, 2019. Program Director will ensure all staff are educated on the new form by September 15,2019. |
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 project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire or ambulance personnel.
There was an unusual incident report documented on July 14, 2019 involving the use of ambulance services to transport a client to the emergency room. The unusual incident report was not submitted to the Department of Drug and Alcohol Programs as specified in the regulations.
There was an unusual incident report documented on July 13, 2019 involving the use of ambulance services to transport a client to the emergency room. The unusual incident report was not submitted to the Department of Drug and Alcohol Programs as specified in the regulations.
There was an unusual incident report documented on February 2, 2019 involving the use of ambulance services to transport a client to the emergency room. The unusual incident report was not submitted to the Department of Drug and Alcohol Programs as specified in the regulations.
There was an unusual incident report documented on January 6, 2019 involving the use of ambulance services to transport a client to the emergency room. The unusual incident report was not submitted to the Department of Drug and Alcohol Programs as specified in the regulations.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed protocol for reporting unusual incidents during clinical meeting on August 27, 2019. Reviewed forms to be completed and faxed within 72 hours of incident. Lead counselors and program director will be responsible for completion of reports. All incident reports upon completion will be uploaded to Pyramid Smartsheet, to be reviewed for accuracy and completion by Clinical Compliance team. Program Director and risk committee will review onsite incident reports weekly to ensure proper unusual incident reports are completed. |