INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Tradition 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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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 the clinical supervisor's completion of a core curriculum in clinical supervision.
Employee #3 was hired as a clinical supervisor on June 28, 2020 and was still in the position as of the date of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor is scheduled for clinical supervisor training August 23-27, 2021. Executive Director will ensure all training requirement are met within required times frames. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employee #6 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe. Employee #7 failed to be receive 4 hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #6 was hired as a support staff on July 15, 2019 and was due to have the communicable disease training no later than July 15, 2021. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #7 was hired as a support staff on April 3, 2019 and was due to have TB/STD training no later than April 3, 2021. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of this inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
BHT Supervior, Clinical Supervisor and Executive Director will ensure all training hours are completed for all employees. Executive Director reviewed training guidelines during staff meeting held on August 3, 2021. All Supervisors will complete a written report monthly, reviewing staff's training needs. All staff who were out of compliance have been scheduled for the next available training in December 20, 2021. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure employee #8 received CPR certification and first aid training.
Employee #8 did not have First Aid or CPR training. She worked solo on May 6, 2021 and May 23, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
BHT supervisor will ensure all staff are CPR certified. BHT supervisor will ensure no staff are scheduled to work alone if they do not hold a present certification. This employee no longer works at the facility, so training could not be scheduled. |
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.
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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 25 clock hours of annual training required for counselors in employee #5's employee record.
Employee #5 was hired as a counselor on November 3, 2019 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 1, 2020 through December 31, 2020. Employee #5's employee record only documented 17 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
Clinical Supervisor will ensure all counselors are scheduling trainings and maintaining their required 25 clock hours each year. Clinical Supervisor will monitor training hours each month, to ensure they are being completed. This was addressed during clincial team meeting on August 3, 2021. |
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.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the hot water did not exceed 120 degrees Fahrenheit. The water temperature in the first floor bathroom sink was 138 degrees, and the water temperature in the basement bathroom sink was 124 degrees. This deficiency was corrected during the licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance was able to correct water temperature during site visit. Maintenance will continue to monitor temperatures monthly for ongoing compliance and safety. They will also be adding a cage to the temperate gage, to ensure staff and clients are unable to change the temperature themselves. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from August 2019 to June 2021, the facility failed to maintain a written fire drill log including the time on logs dated April 20, 2020 and March 19, 2020. Additionally, the facility failed to document the exit route used on logs dated April 15, 2021 and May 10, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Maintenance Supervisor met on August 5, 2021 to review fire drill guidelines. Maintenance will utilize the online reporting system each month. Executive Director and Maintenance Supervisor will ensure form is complete and accurate. |
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.
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Observations
Based on a review of fire drill logs from August 2019 to June 2021, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There were no fire drills conducted during sleeping hours during this time period.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed regulations with Maintenance Supervisor on August 5, 2021. Discussed that sleeping hours are from 11pm to 5am, when the schedule starts for the day. Executive Director and Maintenance Supervisor will review quarterly that a drill was conducted during sleep hours. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill logs from August 2019 to June 2021, the facility failed to set off a fire alarm or smoke detector during fire drills in each of the months documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Maintenance Supervisor reviewed past logs on August 3, 2021. We have a new maintenance worker completing the drills, since 2019. Maintenance Supervisor will continue to monitor compliance and address any further concerns. |
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 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 may not be discriminated against based on religion and creed in seven out of seven records.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual was updated on 7/29/2021 by the Policy and procedure committee to include religion, creed instead of the previously stated religious creed. The new policy was made available to staff on that date via the Pyramid Healthcare intranet. The compliance officer, via email, informed all programs of the change on that date and all handbooks and consents for treatment were amended to reflect the change. |
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 in seven out of seven records.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The PHC compliance officer will be responsible for making an amendment to the electronic health record, specifically the consent for treatment, to include the client's right to appeal the decision limiting access to their records. The PHC compliance officer will ensure this change occurs and is shared with all staff by 9/1/2021. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document in the client records work done at the project as part of treatment in seven out of seven records.
Client #1 was admitted on April 27, 2021 and was still active at the time of the inspection.
Client #2 was admitted on May 20, 2021 and was still active at the time of the inspection.
Client #3 was admitted on May 28, 2021 and was still active at the time of the inspection.
Client #4 was admitted on April 2, 2021 and was discharged on July 1, 2021.
Client #5 was admitted on April 22, 2021 and was discharged on June 14, 2021.
Client #6 was admitted on October 14, 2020 and was discharged on January 29, 2021.
Client #7 was admitted on March 10, 2021 and was discharged on May 9, 2021.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will complete monthly chart audits and ensure all individual session are being completed. Clinical Supervisor will address concerns with clinician during monthly supervision, if there are ongoing issues. These areas of concerns were addressed with clinical during our weekly meeting on August 3, 2021. |