INITIAL COMMENTS
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This report is a result of an on-site, provisional follow up inspection conducted on December 12, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Highland 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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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
Based on a review of the fire drill records and a discussion with facility staff, the facility failed to conduct unannounced fire drills at least once a month.
Fire drill documentation was reviewed from April 2023 to December 2023. A fire drill was not documented for the month of October 2023.
These findings were reviewed with the facility staff during the on-site inspection.
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Plan of Correction
A new Clinical Director was hired on December 19, 2023. She will follow up monthly with the House Manager to ensure the fire drills are being completed as required.
The SCA Management team will also set a reminder to follow up with the Clinical Director the last week of each month to ensure compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to provide case consultations in accordance with the facility policy and procedure in four of seven records.
The facility policy and procedure indicates a case consultation is to occur every thirty days.
Client #3 was admitted on September 26, 2023 and was still a client at the time of the inspection. There was no documentation of a case consultation for October and November 2023.
Client #4 was admitted on October 12, 2023 and was still a client at the time of the inspection. There was no documentation of a case consultation for November 2023.
Client #5 was admitted on September 25, 2023 and was discharged on December 4, 2023. There was incomplete documentation of a case consultation for November 2023.
Client #7 was admitted on August 8, 2023 and was discharged on November 1, 2023. There was no documentation of a case consultation for September and October 2023.
These findings were reviewed with the facility staff during the on-site inspection.
This is a repeat citation from the May 23, 2023 annual licensing inspection.
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Plan of Correction
On December 19, 2023, a Clinical Director was hired. This position has been vacant for several months. Weekly case management meetings were implemented again the end of December and will be ongoing every Tuesday with follow up on Thursday as needed for additional time. Case Consultation due dates and notes will be reviewed during the case management meetings and the team will use a working document to monitor and ensure compliance. In the absence of a Clinical Director, the SCA Assistant Administrator will intervene and ensure the weekly case management teams meetings continue and the case consults are monitored on a continual basis. The process will be reviewed on February 9th, 2024, to ensure it is effective and will address any needed changes to this process at that time. |