INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 13, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sojourner 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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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 personnel and training records, the facility failed to document that the clinical supervisor completed a core curriculum in clinical supervision that was provided and / or approved by the Department in one of one staff record.
Staff #3 was hired as a clinical supervisor on September 13, 2021. Staff #3 does not have documentation of at least 2 years of clinical supervision experience. There was no documentation that staff #3 completed a core curriculum in clinical supervision that was provided by and / or approved by the Department.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical supervisor
will take ddap approved clinical supervisor/supervision training, this will be monitored and followed up by the clinical director and executive director, the clinical supervision training will be for new clinical supervisors. The clinical director/executive director will monitor and assist, so that new supervisors will be registered within 6 months of employment. This will also be documented in the individual training file of staff member.
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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 logs, the facility failed to document unannounced fire drills at least once per month.
The fire drills were reviewed for the period of April 2022 - February 2023. There were no monthly fire drills documented for the months of June, August and September 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Supervisor and lead employee shall conduct, monitor, and document fire drills a minimum of twice per month with an overnight fire drill performed once every six months. The operations supervisor will document in the fire drill log, as well as input the information in the shift report detailing the drills |
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, the facility failed to document fire drills during sleeping hours at least every 6 months.
The fire drills were reviewed for the period of April 2022 - February 2023. The only fire drill conducted during that time period was documented on February 9, 2023. No other fire drills during sleeping hours were documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Supervisor and lead employee shall conduct, monitor, and document fire drills a minimum of twice per month with an overnight fire drill performed once every six months. The operations supervisor will document in the fire drill log, as well as input the information in the shift report detailing the drills. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow written procedures for contacting the emergency contact for clients that leave the facility against medical advice in one of two client records.
Client #6 was admitted August 16, 2022 and was discharged against medical advice on November 8, 2022. Client #6's record did not include documentation that the client's emergency contact was notified of the discharge, as per facility policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will contact the emergency contact on file for any consumer that leaves AMA, within 24 hours. The clinical supervisor will monitor in treatment team meeting as well as update notes for files. |
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 a review of client records, the facility failed to document that the client was notified, in writing, of the decision to involuntarily terminate the client ' s treatment, as well as the reason for termination in one of one client records.
Client #4 was admitted on August 25, 2022 and involuntarily terminated on October 28, 2022. There was no documentation of a written termination notification in client record #4.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The note section shall be updated to document the termination of a consumer, with reason(s) and dates. The consumer will receive a written copy, one will be mailed and a copy in the file. This will be monitored by the clinical supervisor in supervision as well as in treatment team meetings. There will be a copy mailed to the last known address of the consumer. |
709.34 (c) (5) 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:
(5) Outbreak of a contagious disease requiring CDC notification.
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Observations
Based on a review of client records and unusual incident reports, the facility failed to report the outbreak of a contagious disease to the Department within three business days.
During a review of client records, a note was observed stating that two staff members tested positive for COVID-19. This note was dated January 5, 2023. There was no documentation of an unusual incident report sent to the Department within three business days following the positive COVID -19 tests.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility shall report unusual findings and incidents such as outbreaks of any kind within 3 three business days to ddap, as well as update the internal shift reports documenting submissions and reporting. This will be monitored by the operations and clinical supervisors. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document physical examinations within seven days, as per facility policy, in five of seven client records.
Client #1 was admitted on October 6, 2022 and is currently an active client. The physical examination documented in client record #1 was dated December 14, 2022.
Client #3 was admitted on October 13, 2022 and is currently an active client. There was no physical examination documented in client record #3.
Client #5 was admitted on October 13, 2022 and discharged on January 23, 2023. There was no physical examination documented in client record #5.
Client #6 was admitted on August 16, 2022 and discharged on November 8, 2022. There was no physical examination documented in client record #6.
Client #7 was admitted on October 25, 2022 and discharged on December 29, 2022. There was no physical examination documented in client record #7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility has incorporated at intake to call to make a physical examination appointment effective March 09, 2023. This will documented on the notes section of client file. The document will also include the date(s) of the appointment, notes reflective of actual appointment and any cancellations. The physical examination must be scheduled and conducted within 7 days of intake. The scheduled physical examination must accompany a document that service was provided, scheduled and includes the name of the consumer. All other details regarding the physical examination will be filed in the notes section of the consumers file. The scheduled appointment information will also be on internal shift reports documenting the appointment and monitored by the clinical supervisor.
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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 a review of client records, the facility failed to document the type and frequency of services in the treatment plan in seven of seven client records.
The type and frequency of services was not documented on the treatment plans documented in client records #1, 2, 3, 4, 5, 6 and 7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.52 (a) 2
The Facility has incorporated types of services into the treatment plan, which includes internal and external services with frequency of services such as weekly or monthly marked with time frame. This will be monitored by the clinical supervisor in treatment team meetings and noted internally on shift reports.
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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 that work done by the client at the project is an integral part of the treatment plan in seven of seven client records.
The facility utilizes work therapy by means of assigned chores. Work therapy was not documented on the treatment plan in client records #1, 2, 3, 4, 5, 6 and 7.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.53 (a)(12)
The Facility has updated the treatment plan as of March 1, 2023 documenting work therapy as well as the consumer's participation in chores and other life skills in treatment. The clinical and operations supervisor will monitor and document consumer's participation in shift reports, and in the individual treatment plans
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