INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 14-15, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Highland 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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704.11(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 administrative information, the facility failed to ensure CPR certification and first aid training was 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 operations.
Reviewed staff schedules from April 20, 2024 to May 15, 2024. The following dates and times did not have staff people who were CPR certified or trained in first aid:
All day on April 20 and 21.
April 22 from 12 am to 7:30 am and again from 4 pm to 11:59 pm.
April 23 from 12 am to 7:30 am and again from 4 pm to 11:59 pm.
April 24 from 12 am to 7:30 am and again from 4 pm to 11:59 pm.
April 25 from 12 am to 7:30 am and again from 4 pm to 11:59 pm.
April 26 from 12 am to 8 am and again from 12:45 pm to 11:59 pm.
All day on April 27 and 28.
April 29 from 12 am to 7:30 am and again from 4 pm to 11:59 pm.
April 30 from 12 am to 7:30 am and again from 4 pm to 11:59 pm.
May 1 from 4 pm to 11:59 pm.
May 2 from 12 am to 7:30 am and again from 4 pm to 11:59 pm.
May 3 from 2 pm to 11:59 pm.
May 4 from 12 am to 8 pm.
May 5 from 12 am to 8 pm.
May 6 from 12 am to 7:30 am and again from 4 pm to 11:59 pm.
May 7 from 12 am to 7:30 am and again from 4 pm to 11:59 pm.
May 8 from 4 pm to 11:59 pm.
May 9 from 4 pm to 11:59 pm.
May 10 from 12 am to 8 am and again from 3 pm to 11:59 pm.
May 11 from 12 am to 8 pm.
May 12 from 12 am to 8 pm.
May 13 from 12 am to 7:30 am and again from 4 pm to 11:59 pm.
May 14 from 12 am to 7:30 am and again from 4 pm to 11:59 pm.
May 15 from 4 pm to 11:59 pm.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
On May 22, 2024, all of the untrained staff (except for one) were trained on CPR. On May 26, 2024, and May 30, 2024, all of the untrained staff (except for the same one not trained in CPR) were trained on First Aid. On June 19, 2024, the last of the staff was trained on CPR. These two staff members will also be trained on First Aid on July 3, 2024. The certificates will be kept on file for review at the next DDAP visit. Training for CPR and First Aid will be added to the staff training plan and the Executive Director and House Manager will ensure all staff receive the training upon hire. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure staff were instructed in the use of fire extinguishers upon employment in four of four records.
Staff #1 was hired November 20, 2023 and still employed.
Staff #2 was hired December 4, 2023 and still employed.
Staff #3 was hired March 4, 2024 and still employed.
Staff #4 was hired May 6, 2024 and still employed.
No current employees were trained in the use of fire extinguishers at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director or House Manager will ensure that all existing staff are trained on the use of fire extinguishers, provided a PASS diagram on the proper use of a fire extinguisher and that they sign a statement certifying that they have been trained on the proper use of a Fire Extinguisher by July 5th, 2024. This procedure will be followed for all new staff upon hire and will be added to the new staff training plan. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in four of four records.
Staff #1 was hired November 20, 2023 and still employed.
Staff #2 was hired December 4, 2023 and still employed.
Staff #3 was hired March 4, 2024 and still employed.
Staff #4 was hired May 6, 2024 and still employed.
No current employees were trained to perform assigned tasks during emergencies at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director or House Manager will ensure that all existing staff are trained to perform assigned tasks during an emergency and that they sign a statement certifying that they have been trained by July 5th, 2024. This procedure will be followed for all new staff upon hire and added to the new staff training plan. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative information, the facility failed to provide documentation of inspection of storage areas that ensures compliance with state and federals and program policy.
The facility's policy and procedure manual states the inspection of storage areas should be done quarterly. No inspection logs were provided during inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The management staff upgraded the medical storage area to simplify procedures and reduce likelihood of errors. The Clinical Director has been regularly completing inspection of the new medication storage areas. The new management staff recognizes that although the inspections were being completed, it was not documented in writing. Moving forward, the House Manager or Clinical Director will document this is being completed quarterly beginning with quarter ending June 30, 2024. The Clinical Director will provide a copy of the quarterly inspection logs to the Executive Director to ensure compliance. |
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 client records and staff interviews, the facility failed to inform the Department of an unusual incident within the required three days. It was discovered the facility had an unusual incident occur in March 2024 which involved the presence of emergency personnel. Upon further inspection, it was discovered the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The new management was not aware of the requirement to report unusual incidents within three days. As management is now aware of this requirement, management will ensure this is completed.
This is already implemented and can be viewed in the Events Reporting software due to the recent submission on 5/29/24 for a tripped silent alarm that called the police to the house.
The current management has daily communication regarding issues/concerns at the house. Once an issue is identified, the Executive Director will ensure the report is completed as required. |
709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan within the facility's policy timeframe in five of eight applicable records.
The facility's policy and procedure manual states the preliminary treatment plan must be completed within 24 hours following admission.
Client #1 was admitted January 4, 2024 and discharged April 24, 2024. There was no documentation of a preliminary treatment plan at the time of the inspection.
Client #3 was admitted January 3, 2024 and discharged May 9, 2024. There was no documentation of a preliminary treatment plan at the time of the inspection.
Client #4 was admitted March 11, 2024 and still a current client. There was no documentation of a preliminary treatment plan at the time of the inspection.
Client #5 was admitted March 18, 2024 and still a current client. There was no documentation of a preliminary treatment plan at the time of the inspection.
Client #8 was admitted March 20, 2024 and still a current client. There was no documentation of a preliminary treatment plan at the time of the inspection.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Management staff will review this deficiency with clinical staff. The Clinical Director will be responsible for ensuring the counselors complete the preliminary treatment plans within 24 hours. The Clinical Director will review this in the electronic health record and will follow up with clinical staff the following day if one has not been completed. |
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 provide verification that any work done by the client at the project is an integral part of his treatment and rehabilitation plan, in eight of eight applicable residential records reviewed.
There was no documentation on any treatment plan that work done by the client while in residential treatment was an integral part of treatment all records reviewed.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Management will review this deficiency with the clinical staff. The Clinical Director will ensure that the counselors include "Daily completion of chores as assigned." to each treatment plan moving forward. The treatment plans for all current residents have been updated to include this goal. Review of this requirement will be completed at the weekly case management meetings between the Clinical Director, Case Manager and the Counselors. |