INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 7, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial House, Inc. 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:
|
Plan of Correction
|
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of five personnel records on June 7, 2021, the facility failed to ensure each counselor shall complete 25 clock hours of training annually in one out of two applicable records reviewed.
Staff # 4 was hired on April 28, 2012 as a counselor and still worked in that capacity at the time of the inspection. Staff #4 only had sixteen hours of documented annual training.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from May 7, 2020.
|
Plan of Correction
The Clinical Supervisor, along with oversite by the Operations Manager, will ensure that counselors understand and participate in 25 hours of training per fiscal year, in compliance with regulatory requirements. Monthly staff supervision will be conducted by and documented by the Clinical Supervisor, tracking training needs and completions. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on a physical site inspection on June 7, 2021, the facility failed to ensure the hot water did not exceed 120 degrees Fahrenheit.
The water in the upstairs bathroom was measured at 140 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Technician Supervisor, along with oversite by the Operations Manager, will adjust the hot water regulator at the facility to ensure that the temperature does not exceed 120 degrees Fahrenheit by 6/8/21.
The Technician Supervisor will test the water temperature monthly to ensure the temperature parameters are met. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of the fire drill log on June 7, 2021, the facility failed to conduct a fire drill during sleeping hours at least every six months.
The last sleeping fire drill documented was on October 9, 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Technician Supervisor, along with over-sight by the Operations Manager, will conduct an overnight fire drill within the 6 month parameters set forth by the regulatory requirements.
An overnight fire drill was conducted 6-13-21 at 12:37am and recorded. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of five personal files on June 7, 2021, the facility failed to complete written individual staff performance evaluations on an annual basis in two out of five personnel reviewed.
Staff #4 was hired on April 28, 2012 as a counselor and was still in that position at the time of the inspection.
The last staff performance evaluation completed was dated April 2020.
Staff #5 was hired on July 21, 2013 as a counselor and was still in that position at the time of the inspection.
The last staff performance evaluation completed was dated April 2020.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor, along with over-sight by the Operations Manager, will complete annual employee evaluations for fiscal year June 30th through July 1st, and the appropriate parties will review and sign as acceptance of the review. |
709.28 (c) (6) 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. The consent must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
|
Observations
Based on a review of client records on June 7, 2021, the facility failed to document a completed informed and voluntary consent to release information form that included a date, event or condition upon which the consent would expire in two out of seven records reviewed.
Client #2 was admitted on April 12, 2021 and was still active at the time of the inspection. The informed and voluntary release forms dated April 12, 2021 to three medical providers, two labs and two funding sources did not include a date, event or condition upon which the consent would expire.
Client #3 was admitted on April 19, 2021 and was still active at the time of the inspection. The informed and voluntary release forms dated April 28, 2021 to a dental provider did not include a date, event or condition upon which the consent would expire.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will ensure that employees are appropriately helping clients complete informed consent with attention to date parameters and expiration events and/or conditions. Monthly chart audits will be conducted by the Clinical Supervisor to ensure compliance. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
|
Observations
Based on a review of client records on June 7, 2021, the facility failed to include documentation of a client orientation which includes familiarization of project policies in four out of seven records reviewed.
Client #4 was admitted on April 4, 2021 and was still active at the time of the inspection. There was no documentation of a client orientation which included familiarization of project policies.
Client #5 was admitted on October 5, 2020 and was discharged on January 3, 2021.
There was no documentation of a client orientation which included familiarization of project policies.
Client #6 was admitted on November 6, 2020 and was discharged on February 4, 2021.
There was no documentation of a client orientation which included familiarization of project policies.
Client #7 was admitted on November 20,2020 and was discharged on February 18, 2021.
There was no documentation of a client orientation which included familiarization of project policies.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will ensure that the Admissions Coordinator is completing the Client Orientation checklist form with the client upon admission to the facility and familiarizing the client with the facility policies.
Monthly chart audits will ensure documentation compliance. |
709.51(b)(2)(ii) LICENSURE Hours of Operation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(ii) Hours of operation.
|
Observations
Based on a review of client records on June 7, 2021, the facility failed to include documentation of a client orientation which included familiarization of hours of operation in four out of seven records reviewed.
Client #4 was admitted on April 4, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which included familiarization of hours of operation.
Client #5 was admitted on October 5, 2020 and was discharged on January 3, 2021.
There was no documentation of a client orientation which included familiarization of hours of operation.
Client #6 was admitted on November 6, 2020 and was discharged on February 4, 2021.
There was no documentation of a client orientation which included familiarization of hours of operation.
Client #7 was admitted on November 20, 2020 and was discharged on February 18, 2021.
There was no documentation of a client orientation which included familiarization of hours of operation.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Operations Manager will modify the Client Orientation form to include hours of operation to reviewed with the client upon admission.
This form was updated 6/22/21 and added to the admissions intake packet and facility policy and procedure. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
|
Observations
Based on a review of client records on June 7, 2021, the facility failed to include documentation of a client orientation which included a fee schedule in four out of seven records reviewed.
Client #4 was admitted on April 4, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which included a fee schedule.
Client #5 was admitted on October 5, 2020 and was discharged on January 3, 2021.
There was no documentation of a client orientation which included a fee schedule.
Client #6 was admitted on November 6, 2020 and was discharged on February 4, 2021.
There was no documentation of a client orientation which included a fee schedule.
Client #7 was admitted on November 20, 2020 and was discharged on February 18, 2021.
There was no documentation of a client orientation which included a fee schedule.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Operations Manager will modify the Client Orientation form to include the fee schedule to be reviewed with the client upon admission.
This form was updated 6/22/21 and added to the admissions intake packet and facility policy and procedure. |
709.51(b)(2)(iv) LICENSURE Services Provided
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iv) Services provided.
|
Observations
Based on a review of client records on June 7, 2021, the facility failed to include documentation of a client orientation which includes familiarization of services provided in four out of seven records reviewed.
Client #4 was admitted on April 4, 2021 and was still active at the time of the inspection.
There was no documentation of a client orientation which includes familiarization of services provided.
Client #5 was admitted on October 5, 2020 and was discharged on January 3, 2021.
There was no documentation of a client orientation which includes familiarization of services provided.
Client #6 was admitted on November 6, 2020 and was discharged on February 4, 2021.
There was no documentation of a client orientation which includes familiarization of services provided.
Client #7 was admitted on November 20, 2020 and was discharged on February 18, 2021.
There was no documentation of a client orientation which includes familiarization of services provided.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Operations Manager will modify the Client Orientation form to include familiarization of services to be reviewed with the client upon admission.
This form was updated 6/22/21 and added to the admissions intake packet and facility policy and procedure. |