INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on April 14, 2021 and April 15, 2021, by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Angel's Light Addiction Specialists 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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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection conducted on April 14, 2021, the facility failed to keep the facility in good repair. In resident bedroom # 16 a broken ceiling light cover was seen. The loose broken piece was positioned directly over the bed.
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Plan of Correction
The facility installed a new ceiling light on 4/26/2021. There is no longer a loose broken piece over the bed.
The technicians will inspect the clients bedroom daily to ensure that all the lights are working. In any repairs are needed, the technician will inform the Facility Director immediately. Maintenance contractor will be contacted to complete the repair as soon as possible.
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705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection conducted on April 14, 2021, a portable heater was found on the premises in the Clinical Director's office.
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Plan of Correction
The portable heater was removed off the Clinical Director's office the day of the site inspection (04/23/2021).
The Facility Director will check the offices daily to ensure there are no portable heaters.
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709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
Based on staff interviews, client interviews, grievances, incident reports and a review of staff rules of conduct, the facility failed to comply with the procedures written in policy # 3 in the Administration section titled: Organization Ethics, under Ethical Code of Conduct, point # 8 titled: Boundaries. The second paragraph states:
"Staff should treat colleagues with respect, courtesy, fairness, and good faith and shall afford the same to others. Staff communication with clients, colleagues, and any other stakeholders shall do so in a conversational tone free of profanity, criticism, and patronization. Staff will promote client self-determination by refraining from communicating personal opinions concerning political, religious, and sexual preferences. Staff should exhibit courtesy and rational thinking in situations of conflict."
Documentation was observed in regards to a staff member exhibiting behaviors toward colleagues and clients that were described as disrespectful, discourteous, harassing, arguing and intimidating.
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Plan of Correction
Training session scheduled for all staff members to review Code of Ethics, Non violent practices and Workplace violence.
Training date is 05/6/20201 at 2.30 pm.
The training is conducted by the Project Director, Diana Chekrallah.
The person who violated the Code of Ethics was addressed by the Board of Directors, which was recorded in the person personnel file.
Project Director receives staff and clients grievances and complaints.
Further violations by this staff member will result in further discipline process.
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709.30 (1) 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.
(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.
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Observations
Based on client interviews, staff interviews, grievances, incident reports and a review of the client rights on April 14, 2021 and April 15, 2021, it appears that the facility failed to adhere to the Clients Rights. The following rights and liberties were infringed upon:
"Right to be free from physical and verbal abuse"
"Right to be free from retaliation, humiliation and neglect"
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Plan of Correction
Training session with all staff is scheduled to review Patient Rights, including rights and liberties were infringed upon:
"Right to be free from physical and verbal abuse"
"Right to be free from retaliation, humiliation and neglect"
Training date is 5/6/2021 at 2.30 pm.
The training is conducted by the Project Director, Diana Chekrallah.
The person who violated client rights was addressed by the Board of Directors, which was recorded in the person personnel file.
Project Director receives staff and clients grievances and complaints.
Further violations by this staff member will result in further discipline process. |
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 the review of the unusual incidents reported in 2021, the facility failed to notify the Department with 3 business days of an outbreak of a contagious disease requiring CDC notification. An incident report dated 1/25/21 noted that a client received a positive COVID test.
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Plan of Correction
The facility noticed that many emails were not sent from the employees emails due to poor wifi and internet connection in the building.
This was the case for the unusual incident dated 1/21/21 in regards to positive Covid client.
On 4/23/2021 the IT was on site and completed work to strengthen the internet connection and wifi in the building.
As result, there should be no longer issues in transmitting the unusual incident reports within the timeline required by the regulation.
Project Director will ensure that all unusual incident reports are reported to the department within the timeline required by the regulation. |