INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 4, 2023 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:
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Plan of Correction
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705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to keep cooking and eating utensils in a clean and enclosed area. Cooking utensils were being stored hanging in an open area in the kitchen. Silverware was being stored in the cafeteria in bins that were not covered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Operations Manager has ordered closed containers for all eating and cooking utensils in the kitchen. All utensils will be covered moving forward.
Staff training held by Tech Supervisor on 05/11/2023 informing the Behavioral Health Techs and Food Service Specialist of regulations and ensuring compliance moving forward. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection, the facility failed to clearly indicate exits by use of signs in the basement second exit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance Manager and Operations Manager have cleared a path to second exit, placed an exit sign, cleaned the exit stairs, and provided light to the stairwell to improve access and safety. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection, the facility failed to always light interior exits and stairs. The basement exit stairs did not have a light.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance Manager and Operations Manager have cleared a path to second exit, placed an exit sign, cleaned the exit stairs, and provided light to the stairwell to improve access and safety. |
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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client record # 6.
Client # 6 was admitted on February 1, 2023 and was discharged March 7, 2023. A correspondence with a funding source allowing discharge information, symptoms and behaviors, and medications dated March 7, 2023 did not have a valid informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with Clinical team on 05/10/2023 and reviewed the process for signing funding source releases, particularly when a client switches from SCA to Medicaid funding while in treatment.
Clinical Supervisor and Admissions Coordinator will audit specific charts where funding source changes throughout treatment for compliance with implementing a new funding source consent. |
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
Based on six of six applicable client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their rights on the basis of discrimination of services to include ethnicity, sexual orientation, handicap, religion, and marital status in client record # ' s 1, 2, 3, 4, 6, and 7.
Client # 1 was admitted on March 9, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include ethnicity, sexual orientation, handicap, religion, and marital status.
Client # 2 was admitted on March 11, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include ethnicity, sexual orientation, handicap, religion, and marital status.
Client # 3 was admitted on April 20, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include ethnicity, sexual orientation, handicap, religion, and marital status.
Client # 4 was admitted on March 20, 2023 and was discharged April 22, 2023. Client rights provided in the client record did not include ethnicity, sexual orientation, handicap, religion, and marital status.
Client # 6 was admitted on February 1, 2023 and was discharged March 7, 2023. Client rights provided in the client record did not include ethnicity, sexual orientation, handicap, religion, and marital status.
Client # 7 was admitted on March 31, 2023 and was discharged April 3, 2023. Client rights provided in the client record did not include ethnicity, sexual orientation, handicap, religion, and marital status.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director replaced the Client Rights form in the EMR with an updated one, including the following information:
1. A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2. The facility 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.
3. Clients have the right to inspect their own records. The executive 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.
4. Clients have the right to appeal a decision limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoranda to their own records.
All clients sign the Client Rights form upon admission. All clients receive a copy of the Client Rights as included in the Client Handbook. |
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 six of six applicable client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the 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 and reasons for removing sections shall be documented in the record in client record # ' s 1, 2, 3, 4, 6, and 7.
Client # 1 was admitted on March 9, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include written acknowledgment by the client that the 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 and reasons for removing sections shall be documented in the record.
Client # 2 was admitted on March 11, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include written acknowledgment by the client that the 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 and reasons for removing sections shall be documented in the record.
Client # 3 was admitted on April 20, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include written acknowledgment by the client that the 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 and reasons for removing sections shall be documented in the record.
Client # 4 was admitted on March 20, 2023 and was discharged April 22, 2023. Client rights provided in the client record did not include written acknowledgment by the client that the 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 and reasons for removing sections shall be documented in the record.
Client # 6 was admitted on February 1, 2023 and was discharged March 7, 2023. Client rights provided in the client record did not include written acknowledgment by the client that the 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 and reasons for removing sections shall be documented in the record.
Client # 7 was admitted on March 31, 2023 and was discharged April 3, 2023. Client rights provided in the client record did not include written acknowledgment by the client that the 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 and 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
Executive Director replaced the Client Rights form in the EMR with an updated one, including the following information:
1. A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2. The facility 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.
3. Clients have the right to inspect their own records. The executive 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.
4. Clients have the right to appeal a decision limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoranda to their own records.
All clients sign the Client Rights form upon admission. All clients receive a copy of the Client Rights as included in the Client Handbook. |
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 six of six applicable client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their right to appeal a decision limiting access to their records to the director in client record # ' s 1, 2, 3, 4, 6, and 7.
Client # 1 was admitted on March 9, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include their right to appeal a decision limiting access to their records to the director.
Client # 2 was admitted on March 11, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include their right to appeal a decision limiting access to their records to the director.
Client # 3 was admitted on April 20, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include their right to appeal a decision limiting access to their records to the director.
Client # 4 was admitted on March 20, 2023 and was discharged April 22, 2023. Client rights provided in the client record did not include their right to appeal a decision limiting access to their records to the director.
Client # 6 was admitted on February 1, 2023 and was discharged March 7, 2023. Client rights provided in the client record did not include their right to appeal a decision limiting access to their records to the director.
Client # 7 was admitted on March 31, 2023 and was discharged April 3, 2023. Client rights provided in the client record did not include their 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
Executive Director replaced the Client Rights form in the EMR with an updated one, including the following information:
1. A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2. The facility 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.
3. Clients have the right to inspect their own records. The executive 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.
4. Clients have the right to appeal a decision limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoranda to their own records.
All clients sign the Client Rights form upon admission. All clients receive a copy of the Client Rights as included in the Client Handbook. |
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 six of six applicable client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records in client record # ' s 1, 2, 3, 4, 6, and 7.
Client # 1 was admitted on March 9, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
Client # 2 was admitted on March 11, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
Client # 3 was admitted on April 20, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
Client # 4 was admitted on March 20, 2023 and was discharged April 22, 2023. Client rights provided in the client record did not include their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
Client # 6 was admitted on February 1, 2023 and was discharged March 7, 2023. Client rights provided in the client record did not include their right to request the correction of inaccurate, irrelevant, outdated, or incomplete information in their records.
Client # 7 was admitted on March 31, 2023 and was discharged April 3, 2023. Client rights provided in the client record did not include their 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
Executive Director replaced the Client Rights form in the EMR with an updated one, including the following information:
1. A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2. The facility 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.
3. Clients have the right to inspect their own records. The executive 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.
4. Clients have the right to appeal a decision limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoranda to their own records.
All clients sign the Client Rights form upon admission. All clients receive a copy of the Client Rights as included in the Client Handbook. |
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 six of seven client records reviewed, the facility failed to provide documentation of written acknowledgment by the client that the client had been made aware of their right to submit rebuttal data or memoranda to their own records in client record # ' s 1, 2, 3, 4, 6, and 7.
Client # 1 was admitted on March 9, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include their right to submit rebuttal data or memoranda to their own records.
Client # 2 was admitted on March 11, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include their right to submit rebuttal data or memoranda to their own records.
Client # 3 was admitted on April 20, 2023 and was still active at the time of the inspection. Client rights provided in the client record did not include their right to submit rebuttal data or memoranda to their own records.
Client # 4 was admitted on March 20, 2023 and was discharged April 22, 2023. Client rights provided in the client record did not include their right to submit rebuttal data or memoranda to their own records.
Client # 6 was admitted on February 1, 2023 and was discharged March 7, 2023. Client rights provided in the client record did not include their right to submit rebuttal data or memoranda to their own records.
Client # 7 was admitted on March 31, 2023 and was discharged April 3, 2023. Client rights provided in the client record did not include their 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
Executive Director replaced the Client Rights form in the EMR with an updated one, including the following information:
1. A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
2. The facility 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.
3. Clients have the right to inspect their own records. The executive 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.
4. Clients have the right to appeal a decision limiting access to their records to the director.
5. Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
6. Clients have the right to submit rebuttal data or memoranda to their own records.
All clients sign the Client Rights form upon admission. All clients receive a copy of the Client Rights as included in the Client Handbook. |
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 one of one applicable client record reviewed, the facility failed to provide documentation of the project notifying the client, in writing, of a decision to involuntarily terminate the client's treatment in client record # 4.
Client # 4 was admitted on March 20, 2023 and discharged on April 22, 2023. There was no documentation in the client record notifying the client in writing of termination from the project.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Notification of Treatment Termination Form was developed by Executive Director and implemented into current EMR effective 05/05/2023.
Clinical Supervisor reviewed in staff meeting on 05/10/2023 the expectation that Executive Director would complete this form upon the involuntary termination of treatment of a client and Counselor would submit the form to the client. The form will include the reason for termination and will indicate that client shall have an opportunity to request reconsideration of a decision termination his treatment. |
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
Based on a review of the facility unusual incident log, the facility failed to report to the department within 3 business days two unusual incidents requiring the presence of police, fire or ambulance personnel.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon review of DDAP unusual incident reporting regulations and the facility unusual incident report binder, Executive Director submitted outstanding incident reports electronically to the department on 05/23/2023.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. 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 four of five applicable client records reviewed, the facility failed to provide an individual treatment and rehabilitation plan developed with the client to include the type and frequency of treatment and rehabilitation services.
Client # 1 was admitted on March 9, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on March 14, 2023. There was no documentation of type and frequency of services.
Client # 2 was admitted on March 11, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on March 17, 2023. There was no documentation of type and frequency of services.
Client # 3 was admitted on April 20, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan was developed with the client on April 25, 2023. There was no documentation of type and frequency of services.
Client # 4 was admitted on March 20, 2023 and was discharged April 22, 2023. A comprehensive treatment and rehabilitation plan was developed with the client on March 24, 2023. There was no documentation of type and frequency of services.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with the Clinical team on 05/11/2023 and Clinical staff were instructed to note type and frequency of services as "Group Therapy 5-7x/week" and "Individual Therapy 1x/week" on all treatment plans, as applicable.
Clinical team expressed understanding and has been implementing the suggested format, as evidenced by weekly chart audits by Clinical Supervisor.
Clinical Supervisor will audit all treatment plans for compliance weekly and upon discharge. |