INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 2023 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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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
Based on a review of the policy manual, the facility failed to document a policy to address relapse of recovering clinical personnel and the discipline of non-recovering employee who abuse alcohol and other drugs.
The facility attestation forms, completed by facility staff, indicated that the facility policy had been changed within the last licensing review period. The policy was updated; however, the revision included the re-stated regulation and did not address all areas.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Salvation Army Harbor Light Center has a policy to review suspected substance use by any employee. The Director will distribute the policy and procedures to supervisors (Clinical Supervisor and Office Manager). The policy includes a checklist to complete with the employee, a detailed procedure of how to handle the suspected use situation, documentation to include, and who to notify. The immediate supervisor of the employee suspected of relapse is responsible for completing these steps. In their absence, the Director will be responsible for completing these steps. This procedure also includes steps that will be taken for the employee if substance use is confirmed. All policies surrounding substance use in the workplace are available for review. |
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records, the facility failed to document that all counselors met the educational and experience requirements for the position in one of two records reviewed.
Staff #3 was hired on March 8, 2017 and promoted to counselor on May 1, 2022. Staff #3 holds a High School diploma, which does not meet the educational requirements for the position of counselor. No other qualifying certifications were documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff #3 was promoted to counselor assistant on 05.01.2021. He worked under close supervision through 9.06.2021; at that time a performance evaluation was completed to review the staff member's duties as a counselor assistant. From September 2021 through May 2022 Staff #3 was monitored while providing clinical activities by Clinical Supervisor.
At present time Staff #3 has provided his high school transcripts. Staff #3's college transcripts will be ordered as well. This documentation, along with training and supervision hours, will be sent to the Pennsylvania Certification Board so that staff #3 can apply for certification as a drug and alcohol counselor.
In the meantime, Staff #3 will remain a counselor assistant until the qualifications for the position of counselor are met.
The Clinical Supervisor and Director will continue to ensure that all staff hired or promoted to the position of counselor meet both the educational and experiential requirements for the position.
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the policy manual, the facility failed to document procedures to address staff development.
The facility attestation forms, completed by facility staff, indicated that the facility policy had been changed within the last licensing review period. The revision included the re-stated regulation and did not include procedures for (1) An assessment of staff training needs, (2) An overall plan for addressing these needs, (3) A mechanism to collect feedback on completed training, (4) An annual evaluation of the overall training plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor and Director updated the policy titled Staff Training to clarify that Harbor Light Center will be utilizing a fiscal calendar, July 1 to June 30, to track trainings. In addition, the policy now reflects the following procedures:
Beginning in May of the current year, annual training plans will be completed for each staff member at The Salvation Army Harbor Light Center. Each staff will review their training plan with their immediate supervisor/Director where new training needs will be assessed and identified and added to the annual plan. Each training plan will be evaluated annually by the Program Director and Clinical Supervisor to assess if all needs are being met for staff.
The Program Director, on the basis of these identified needs and individual training plans, will formulate a staff training schedule for the upcoming year to be implemented July 1st, delineating topics for presentation, anticipated date of presentation, and the presenter. Past training evaluations will be reviewed to inform the new training schedule.
The Program Director will also ensure annual training needs according to all licensing requirements are met, such as CPR/AED, First Aid, fraud waste and abuse, etc. are all scheduled within the fiscal year.
All Clinical Staff members will be responsible for completing a minimum of 24 hours of training per fiscal year. All administrative and support staff will be responsible for completing a minimum of 18 hours of training per fiscal year.
After completion of each training, staff will provide proof of completion and an evaluation of both internal and external training to the Administrative Secretary within five (5) business days following the training attendance. These evaluations will be reviewed by the Clinical Supervisor so that recommendations can be made for future trainings. The Administrative Secretary will track completion of trainings and will maintain documentation as a permanent portion of the personnel file.
The Administrative Secretary and the Executive Director will monitor training plan progress at the end of each quarter. Any missed or incomplete trainings will be scheduled within the fiscal year as needed to maintain requirements. At the end of the third quarter, any staff found to be at risk of noncompliance with licensing requirements, or at risk of not meeting fiscal year deadlines, will be prompted to register and complete training. Such staff will be placed on a Performance Improvement Plan as appropriate to ensure trainings are completed by June 30th.
The updated policy is available for review. |
705.10 (a) (1) (ii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(ii) Maintain a minimum of two exits on every floor, including the basement, that are separated by a minimum distance of 15 feet.
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Observations
Based on a physical plant inspection, the facility failed to maintain at least two exits from every floor.
A physical plant inspection was conducted on February 6, 2023 at approximately 10:00 AM. During the physical plant inspection, the second floor was observed to be used as a multi-purpose area including storage. The second floor was observed to only have one exit - the main stairway. No other exits from this floor were observed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Harbor Light Center has begun the removal of all items within the second floor storage area. All clothing, toiletries, and other items will be removed from this storage area and placed in to a room on the third floor that does meet regulation of having 2 exits. Once all items are removed a sign stating "NO ACCESS" will be placed on the second floor door and the door will remain locked at all times so no one can access the area. The Office Manager is responsible for ensuring this is completed by 5.01.2023. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow written procedures for the management of treatment/rehabilitation services for clients in one of one client records.
Client #5 was admitted October 11, 2022 and was discharged against medical advice on January 17, 2023. Client #5 ' s record did not contain documentation that the client ' s emergency contact was notified of the discharge, as per facility policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Discharge Letters will be completed by the assigned Therapist and reviewed by the Clinical Supervisor or Director. Starting 3.1.2023 the Clinical Supervisor will notify emergency contacts for all residents that discharge the program Against Program Advice; Clinical Supervisor will complete required documentation to support this. Clinical Supervisor will attempt contact with the emergency contact within 24 hours of the client's discharge. Clinical Supervisor will place the documentation within the file within 72 hours of the attempted contact. The Clinical Supervisor will discuss all such discharges with the Director and will complete a chart review upon discharge to ensure discharge procedures were followed. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
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Observations
Based on a review of the policy manual and staff interview, the facility failed to ensure that only individuals permitted by Pennsylvania law administer medication.
During inspection of the facility ' s medication room, facility staff were interviewed on the method in which medication is distributed. Facility staff stated that medication is taken out of blister packs, put into a paper cup, and then given to the client by staff who are not permitted to administer medication by Pennsylvania law. The facility ' s policy manual also stated that medication is to be passed from staff to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Harbor Light Center has updated the Medication Policy to reflect client self-administration with observation by HL staff. The Clinical Supervisor has made all staff aware of this update and are now utilizing the client self-administration process for medications. The Clinical Supervisor will provide training to new employees upon hire and re-training for current employees on the Medication Policy by 5/1/2023. The policy is available for review. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project in one of one client records.
Client #4 was admitted on July 5, 2022 and was involuntarily terminated on October 20, 2022. The notice documented in the client record did not include the reason for termination, it stated " other issues " .
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each client receiving an involuntary termination will be provided written notice of the termination. The Clinical Supervisor has updated the Discharge Letter to include an area for more information to be written to detail the events surrounding the discharge, if necessary. This Discharge Letter will be completed by the assigned Therapist and reviewed by the Clinical Supervisor or Director. All clients will be provided this letter at the time of discharge/termination. If the client leaves the program AFA, without completing aftercare documents, then a copy of the letter will be mailed to the address on file for the client. A copy of the mailing will be put in to the client's chart. The Clinical Supervisor will complete a chart review upon discharge to ensure this procedure is followed. A sample of this letter is available for review. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide the client an opportunity to request reconsideration of a decision terminating treatment in one of one client records.
Client #4 was admitted on July 5, 2022 and was involuntarily terminated on October 20, 2022. Client #4 ' s record did not contain documentation that an opportunity to request reconsideration of a decision terminating treatment was offered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has updated the Discharge Letter to include the client right to appeal the decision of termination and the process to appeal the decision. This Discharge Letter will be completed by the assigned Therapist and reviewed by the Clinical Supervisor or Director. All clients will be provided this letter at the time of discharge/termination and notified of their right to appeal. If the client leaves the program without completing aftercare documents then the letter will mailed to the address on file. A copy of the mailing will be put in to the client's chart. The Clinical Supervisor will complete a chart review upon discharge to ensure this procedure is followed. A sample of this letter is available for review. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to assure that counseling services are provided according to the individual treatment and rehabilitation plan in five of seven client records.
Client #1 was admitted December 5, 2022 and was active at the time of the inspection. All of the treatment plans and updates documented in client #1 indicated that family sessions were to be conducted one time per month. There were no family sessions documented in client record #1.
Client #2 was admitted December 8, 2022 and was active at the time of the inspection. All of the treatment plans and updates documented in client #2 indicated that family sessions were to be conducted one time per month. There were no family sessions documented in client record #2.
Client #3 was admitted December 29, 2022 and was active at the time of the inspection. All of the treatment plans and updates documented in client #3 indicated that family sessions were to be conducted one time per month. There were no family sessions documented in client record #3.
Client #4 was admitted July 5, 2022 and was discharged October 20, 2022. All of the treatment plans and updates documented in client #4 indicated that family sessions were to be conducted one time per month. There were no family sessions documented in client record #4.
Client #5 was admitted October 11, 2022 and was discharged January 17. 2023. All of the treatment plans and updates documented in client #5 indicated that family sessions were to be conducted one time per month. There were no family sessions documented in client record #5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will review individual treatment plans as part of regular supervision to ensure individual treatment and rehabilitation plans are followed. The Clinical Supervisor will also conduct regular chart audits to ensure individual treatment and rehabilitation plans are followed.
The Clinical Supervisor has removed the line from the treatment plan that identifies family sessions as a monthly requirement. Instead, clients and their therapists will collaborate to develop action steps and goals to incorporate family in to treatment at the client's request and as appropriate for the client's outlined goals. All therapists and counselors will adhere to the family session commitment set forth by the client's developed treatment plan. The Clinical Supervisor will conduct regular chart audits to ensure individual treatment and rehabilitation plans are followed. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a record of service in seven of seven client records.
Client records #1, 2, 3, 4, 5, 6, and 7 did not include documentation of a record of services provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Harbor Light Center will implement record of service for all client charts beginning on 4.1.2023. The Clinical Supervisor will monitor compliance during bi-weekly chart audits. The Clinical Supervisor will address training on this and completion as necessary. |
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 client records, facility policy and staff interview, it was determined that work therapy is being utilized by all clients. The facility failed to make work therapy an integral part of the treatment and rehabilitation plan in seven of seven client records.
Work therapy was not documented in treatment plan or treatment plan updates in client records #1, 2, 3, 4, 5, 6, 7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor will work with therapists to build work therapy in to every client's treatment plan beginning on 4.1.2023. For existing clients, work therapy will be added in to the treatment plan update closest to the 4.1.2023 date and all new admissions moving forward will include work therapy in to their treatment plan. All residents complete work therapy details; these are assigned based upon the client's ability to physically participate. All progress with work therapy details will be included in treatment plan updates just as other goal progression is. The Clinical Supervisor will conduct regular chart audits to ensure that work therapy is part of treatment plans as appropriate. |