INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on May 8-10, 2024 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Sojourner House, Inc was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.10 (b) (3) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(3) Repair inoperable smoke detectors or fire alarms within 48 hours of the time the detector or alarm is found to be inoperative.
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Observations
Based on a review of fire drill logs and administrative documentation, the facility failed to repair inoperable smoke detectors or fire alarms within 48 hours of the time that the detector or alarm was found to be inoperative.
The fire drill report dated January 29, 2024 indicated that the fire alarm panel was down. A repair receipt was provided; however, the date of the repair was February 5, 2024, which was not within 48 hours that the equipment was found to be inoperable.
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Plan of Correction
Sojourner House fire alarm system has been repaired and has scheduled quarterly inspections of the fire system to ensure the system stays operable. Sojourner House staff has been instructed to conduct security checks hourly and document the security checks to ensure safety should the system becomes inoperable. The Recovery Support Supervisor will schedule fire alarm inspections quartley. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client medication administration records, the facility failed to provide documentation of medication being provided as prescribed by a physician.
Client #1 was admitted on April 18, 2024 and discharged on May 1, 2024. Client #1 prescribed a medication on April 24, 2024 that was supposed to be taken once per day. The medication administration record showed that the client did not receive the medication as prescribed on Apri 25, 26, 27 and 29. There was no comment or note documented to indicate a reason why the medication was not taken as prescribed.
Client #2 was admitted on October 5, 2023 and discharged on April 29, 2024. Client #2 prescribed a medication on February 23, 2024 that was supposed to be taken once per day in the morning. The medication administration record showed that the client did not receive the medication as prescribed on April 13, 14, 15, 16, 17, 18 and 19. There was no comment or note documented to indicate a reason why the medication was not taken as prescribed.
Client #2 was prescribed another medication that was to be taken from April 12 - 16, 2024. The medication was not taken as prescribed on April 12, 13, 15 and 16. There was no comment or note documented to indicate a reason why the medication was not taken as prescribed.
Client #2 was prescribed another medication on February 7, 2024 that was to be taken twice daily. The medication was not taken as prescribed on April 7, 11, 14, 17, 18, 19, 20, 27, 28, 29 and 30. There was no comment or note documented to indicate a reason why the medication was not taken as prescribed.
Client #4 was admitted on February 14, 2024 and was active at the time of the investigation. Client #4 prescribed a medication on April 11, 2024 that was supposed to be taken twice per day. The medication administration record showed that the client did not receive the medication as prescribed on April 12, 14, 15, 16, 18, 19, 20, 21, 22, 23, 24, 25, 26, 28 and 29. There was no comment or note documented to indicate a reason why the medication was not taken as prescribed.
Client #4 was prescribed another medication on March 19, 2024 that was to be taken twice daily. The medication was not taken as prescribed on April 6, 7, 15, 16 and 20. There was no comment or note documented to indicate a reason why the medication was not taken as prescribed.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Sojourner House has updated the electronic medication system. The support staff have been trained to use the system for monitoring, recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date, and reason for missed dosage. The recovery support supervisor will review the patient and childrens medical record weekly. |
709.52(d) LICENSURE Regularity of counseling provided
709.52. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis.
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Observations
Based on a review of client records and group therapy sign in sheets, the facility failed to provide counseling on a regular and scheduled basis, as per facility policy.
The facility policy states that individual therapy sessions are to be held weekly and group therapy sessions are to be held daily, with two groups being provided daily Monday - Friday.
The most recent annual inspection was held on March 5-7, 2024. The client record review focused on the time period of April 1 - May 8, 2024.
Client #1 was admitted on April 18, 2024 and discharged on May 1, 2024. There was no documentation that the client had an individual therapy session for the week of April 21, 2024. There was no documentation of any group therapy sessions for April 20, 21, 26, 27 and 28. Only one group therapy session was documented for April 18, 19, 23, 24, 25, 29 and 30.
Client #2 was admitted on October 5, 2023 and discharged on April 29, 2024. There was no documentation of any group therapy sessions for April 6, 7, 10, 11, 13, 14, 20, 21, 27, 28, 29 and 30. Only one group therapy session was documented for April 3, 4, 12, 15, 16, 17, 23, 24 and 26.
Client #3 was admitted on January 16, 2024 and was and active client at the time of the investigation. There was no documentation that the client had individual therapy sessions for the weeks of April 14 & 21, 2024. There was no documentation of any group therapy sessions for April 6, 7, 13, 14, 23, 27, 28 and May 2, 3 and 5. Only one group therapy session was documented for April 3, 4, 5, 11, 12, 15, 16, 17, 18, 19, 20, 21, 22, 24, 25, 26, 29, 30 and May 1, 4, 5, 6 and 7.
Client #4 was admitted on February 14, 2024 and was and active client at the time of the investigation. There was no documentation of any group therapy sessions for April 6, 7, 11, 13, 14, 16, 20, 21, 23, 27, 28 and May 2, 3 and 5. Only one group therapy session was documented for April 3, 8, 15, 17, 24, 26, 29, 30 and May 4, 6 and 7.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Sojourner House's clinical staff has been instructed to conduct a minimum of one hour of individual therapy sessions on their assigned client weekly, documenting the session in the electronic record system. The counselors will conduct and document group therapy sessions that are held daily as scheduled. To ensuring two groups being provided daily Monday - Friday. The clinical supervisor will monitor the electronic daily to ensure all individual and group sessions are completed and documented according to our policy and procedures. |
709.53(a)(5) LICENSURE Progress 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:
(5) Progress notes.
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Observations
Based on a review of client records and group sign in sheets, the facility failed to document progress notes for completed group therapy sessions.
The most recent annual inspection was held on March 5-7, 2024. The client record review focused on the time period of April 1 - May 8, 2024.
Client #1 was admitted on April 18, 2024 and discharged on May 1, 2024. A client sign in was documented for group therapy on April, 23, 2024; however, there was no corresponding progress note documented in the client record.
Client #2 was admitted on October 5, 2023 and discharged on April 29, 2024. Client sign ins were documented for group therapy twice on April 1 and April 23 and once on April 2, 2024; however, there were no corresponding progress notes documented in the client record for these sessions.
These findings were reviewed with facility staff during the investigation process.
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Plan of Correction
Sojourner House's clinical staff has been instructed to complete and document all group therapy sessions that are held daily as scheduled. The clinical supervisor will ensure a minimum of two groups are being provided daily Monday - Friday. The clinical supervisor will monitor the electronic record system daily to ensure all group sessions are completed and documented according to our policy and procedures. The lead therapist will ensure all weekend groups conducted are documented in the electronic record system and collect all the client sign-in sheets. |