INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 26, 2025, 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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704.11(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, the facility failed to ensure employees received the minimum of at least 4 hours of TB/STD and other health related topics within the first year of employment in one of four records.
Staff #4 was hired as a counselor on August 25, 2023, and was still employed at time of inspection. Staff #4 was due to have the communicable disease trainings no later than August 25, 2024. There was no documentation provided of the completion of the TB/STD training as of the date of the inspection.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Sojourner House's Sr. Clinical Manager and Human Resource Manager will oversee and ensure all counselors and new hires complete least 4 hours of TB/STD training and other health related topics within the first year of employment to be compliant with licensing regulations. All current staff have received the needed training to be compliant with state required regulations |
709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document a purpose of disclosure on the release of information form in one of seven records.
Client #6 was admitted on February 25, 2025, and was still active at time of inspection. A release of information to a funding source was signed and dated by the client on February 25, 2025, but did not indicate a purpose of disclosure.
This finding was reviewed with the facility staff during the licensing process.
This is a repeat citation from the March 5-7, 2024 licensing inspection.
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Plan of Correction
The Sr. Clinical Manager conducted a training and overview with the clinical staff on 3/19/25 on proper documentation on consent to release client information. Sojourner House created a file auditing tool to be reviewed weekly to ensure proper documentation on consents are being completed correctly. The Sr. Clinical Manager will review the audit tool weekly. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
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Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in one of two applicable records.
The facility's policy and procedure states if a client is discharging against facility advice, the Sojourner House staff on duty must call the client's emergency contact and the designated on-call employee immediately.
Client #2 was admitted on January 23, 2025, and discharged on February 02, 2025. There is a consent for the emergency contact in client #2 ' s record.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Sr. Clinical Manager conducted a overview of policy and procedures with staff when patients are discharged. The Sojourner House staff on duty must call the client's emergency contact and the designated on-call employee immediately. The staff has also been instructed to contact the Lead Counselor or Sr. Clinical Manager should a unexpected discharge occurs after regular business hours to ensure staff contacts the clients emergency contact that is required by our policies and procedures. The Sr. Clinical Manager will monitor all patient discharges. |