INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 10, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sarah Jane Bentley Foundation 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project director in employee #1's employee record.
Employee #1 was hired as the project director on December 1, 2020 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 2023 through December 2023. Employee #1's employee record only documented 4 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Sarah Jane Bentley Foundation recognizes that prior deficiencies in October 2023 and January 2024 included training plans, certificates, and feedback. As noted in the deficiency, the facility did not adequately document training during the 2023 calendar year. On January 26, 2024, the Sarah Jane Bentley Foundation engaged a consultant to redesign Human Resources practices, including the documentation and recording of training. These changes included creating an annual training plan for individuals and the facility at large for 2024, creating a training feedback form, and creating a record of training (within the HR file of each employee). Since implementation in May 2024, the Office Manager has maintained the responsibility of recording training, filing certificates, gathering training feedback, and ensuring the accuracy of these records. The Project Director will review HR files quarterly to ensure they are up to date as required. Date of Completion: 06/28/2024. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that staff were instructed in the use of fire extinguishers upon employment.
Employee #2 was hired on January 17, 2024 a counselor and was still in the position as of the date of the inspection. The training was completed on April 24, 2024.
Employee #3 was hired on March 19, 2024 as a counselor and was still in the position as of the date of the inspection. The training was completed on April 24, 2024 .
Employee #4 was hired on April 29, 2024 as a counselor and was still in the position as of the date of the inspection. There was no documentation of the training in the personnel record at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Sarah Jane Bentley Foundation recognizes that prior deficiencies in October 2023 and January 2024 included fire safety training. As noted in the deficiency, the facility did not adequately document fire extinguisher training for staff members. On January 26, 2024, the Sarah Jane Bentley Foundation engaged a consultant to redesign Human Resources practices, including the documentation and recording of training. These changes included the creation of an onboarding packet for each position. The onboarding packet includes a document to record the completion of required training (including Fire Extinguisher training). Since its implementation in May 2024, there have been no hires. Employee number 4 has been enrolled in Fire Extinguisher training and completed it on 06/28/2024. Date of completion 06/28/2024. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #2 was hired on January 17, 2024 a counselor and was still in the position as of the date of the inspection. The training was completed on April 24, 2024.
Employee #3 was hired on March 19, 2024 as a counselor and was still in the position as of the date of the inspection. The training was completed on April 24, 2024 .
Employee #4 was hired on April 29, 2024 as a counselor and was still in the position as of the date of the inspection. There was no documentation of the training in the personnel record at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Sarah Jane Bentley Foundation recognizes that prior deficiencies in October 2023 and January 2024 included fire safety training. As noted in the deficiency, the facility did not adequately document assigned tasks for staff members during emergencies. On January 26, 2024, the Sarah Jane Bentley Foundation engaged a consultant to redesign Human Resources practices, including the documentation and recording of training. These changes included the creation of an onboarding packet for each position. The onboarding packet includes a document to record the completion of required training (including Fire Extinguisher training). Since its implementation in May 2024, there have been no hires. Employee number 4 has been enrolled in emergency preparedness training and is expected to complete it on 06/28/2024. Date of completion 06/28/2024. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of eight client records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #3 was admitted on May 31, 2024 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
709.28(c) The counselor will review client charts to ensure all consents have been signed on the day of admission. Counselors will begin reviewing current charts within 30 days no later than July 30, 2024, to bring charts up to compliance. CS will audit charts to ensure client charts have been updated daily moving forward. CS will complete group supervision to ensure all counselors are trained and understand the importance of completing consent during admission and as needed. CS will review the admission process which consists of but is not limited to the following, consents and admission paperwork. |
709.30 (3) 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.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that the project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.30(3) The "Client Bill of Rights" document in the Electronic Health Record has been updated to include the missing language. Counselors will begin updating client charts to ensure all clients have reviewed and signed the updated client rights form. Counselors will begin reviewing current charts to gain compliance within 30 days no later than July 30, 2024. CS will audit charts to ensure clients have signed the client rights policy and charts have been updated. CS will complete group supervision to ensure all counselors are trained and understand the importance of client rights. The supervisor will continue to audit charts during admission. Counselors will ensure client bills of rights are reviewed and signed annually. CS will review charts daily to ensure charts remain in compliance. The clinical Supervisor will review and introduce peer audits to clinical staff beginning July 30, 2024, to ensure all charts remain in compliance. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to appeal a decision limiting access to their records to the director.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.30 (4) The "Client Bill of Rights" document in the Electronic Health Record has been updated to include the missing language. Counselors will begin updating client charts to ensure all clients have reviewed and signed client rights. Counselors will begin reviewing current charts to gain compliance within 60 days no later than July 30, 2024. CS will audit charts to ensure clients have signed the client rights policy and charts have been updated. CS will complete group supervision to ensure all counselors are trained and understand the importance of client rights. The supervisor will continue to audit charts during admission. Counselors will ensure client bills of rights are reviewed and signed annually. CS will review charts daily to ensure charts remain in compliance. The clinical Supervisor will review and introduce peer audits to clinical staff beginning July 30, 2024, to ensure all charts remain in compliance. |
709.30 (5) 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.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The "Client Bill of Rights" document in the Electronic Health Record has been updated to include the missing language. Counselors will begin updating client charts to ensure all clients have reviewed and signed client rights. Counselors will begin reviewing current charts to gain compliance within 60 days no later than July 30, 2024. CS will audit charts to ensure clients have signed the client rights policy and charts have been updated. CS will complete group supervision to ensure all counselors are trained and understand the importance of client rights. The supervisor will continue to audit charts during admission. Counselors will ensure client bills of rights are reviewed and signed annually. CS will review charts daily to ensure charts remain in compliance. The clinical Supervisor will review and introduce peer audits to clinical staff beginning July 30, 2024, to ensure all charts remain in compliance. |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on a review of client records, the facility failed to inform the client of all of their rights. The client rights form given to the client did not identify that clients have the right to submit rebuttal data or memoranda to their own records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.30(6) The "Client Bill of Rights" document in the Electronic Health Record has been updated to include the missing language. Counselors will begin updating client charts to ensure all clients have reviewed and signed client rights. Counselors will begin reviewing current charts to gain compliance within 60 days no later than July 30, 2024. CS will audit charts to ensure clients have signed the client rights policy and charts have been updated. CS will complete group supervision to ensure all counselors are trained and understand the importance of client rights. The supervisor will continue to audit charts during admission. Counselors will ensure client bills of rights are reviewed and signed annually. CS will review charts daily to ensure charts remain in compliance. The clinical Supervisor will review and introduce peer audits to clinical staff beginning July 30, 2024, to ensure all charts remain in compliance. |
709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan include both short and long term goals in three out of three applicable client records reviewed.
Client #3 was admitted on May 31, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 5, 2024 with no short term goals.
Client #5 was admitted on April 16, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on April 17, 2024 with no short term goals.
Client #6 was admitted on April 8, 2024 and discharged on May 4, 2024. A comprehensive treatment plan was developed on April 8, 2024 with no short term goals.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(a)(1) CS will review the process for completing these deficiencies within 30 days with clinical staff. CS will train clinical staff on the process for completing treatment plans which should include both long-term and short-term goals. CS will review the process for treatment plans which should include duration and frequency of treatment goals. Clinicians will be responsible for correcting deficiencies in current client charts within 30 days. CS will review client charts to ensure these charts have been corrected. Counselors will begin meeting with clients to ensure treatment plans have been signed due to changes. This will ensure these deficiencies do not occur again. The plan is to have these charts updated by July 30, 2024 |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan include type and frequency in two out of three applicable client records reviewed.
Client #3 was admitted on May 31, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 5, 2024 with no type and frequency of treatment and rehabilitation services.
Client #6 was admitted on April 8, 2024 and discharged on May 4, 2024. A comprehensive treatment plan was developed on April 8, 2024 with no type and frequency of treatment and rehabilitation services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(a)(2) CS will review the process for completing these deficiencies within 30 days with clinical staff. CS will train clinical staff in the process of completing treatment plans which should include the type and frequency of rehabilitation. CS will review the process for treatment plans which should include duration and frequency of treatment goals. Clinicians will be responsible for correcting deficiencies in current client charts within 30 days. CS will review client charts to ensure these charts have been corrected. Counselors will begin meeting with clients to ensure treatment plans have been signed due to changes. This will ensure these deficiencies do not occur again. The plan is to have these charts updated by July 30, 2024 |
709.92(a)(3) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(3) Proposed type of support service.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan include proposed type of support service in three out of three applicable client records reviewed.
Client #3 was admitted on May 31, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on June 5, 2024 with no propose type of support services .
Client #5 was admitted on April 16, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on April 17, 2024 with no propose type of support services .
Client #6 was admitted on April 8, 2024 and discharged on May 4, 2024. A comprehensive treatment plan was developed on April 8, 2024 with no propose type of support services .
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.92(a) (3) CS will review the process for completing these deficiencies within 30 days with clinical staff. CS will train clinical staff on the process for completing treatment plans which should include the proposed type of support service. CS will review the process for treatment plans which should include duration and frequency of treatment goals. Clinicians will be responsible for correcting deficiencies in current client charts within 30 days. CS will review client charts to ensure these charts have been corrected. Counselors will begin meeting with clients to ensure treatment plans have been signed due to changes. This will ensure these deficiencies do not occur again. The plan is to have these charts updated by July 30, 2024 |