INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 23, 2021 through February 24, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Adappt 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:
|
Plan of Correction
|
704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
|
Observations
Based on a review of the facility's policy and procedure manual, the facility failed to develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By March 31, 2021, the facility director will develop a comprehensive staff development program for agency personnel. The senior area manager will review and approve the comprehensive staff development program for agency personnel. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that a sufficient number of staff persons were CPR certified and trained in first aid during the project's hours of operation.The facility's hours of operation are Sunday through Saturday, 24 hours a day. The facility failed to provide sufficient CPR and first aid staff coverage during the overnight hours which are from 11:30pm to 6:15am for the period reviewed.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By March 19, 2021, the facility director will determine which employees will be required to complete CPR training in order to provide daily coverage on each shift. By April 2, 2021, the facility director will complete CPR training with all required employees. The facility director will develop a tracking system to verify recertification's are completed on time so there are no lapses in coverage. The senior area manager will monitor the process for 90 days or until compliance is achieved and sustained. |
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.
|
Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors during the prior traning year reviewed in three of three applicable personnel records reviewed. Employee #3's personnel record documented 4 hours of annual training.Employee #4's personnel record documented 7.8 hours of annual training.Employee #5's personnel record documented 3 hours of annual training. These findings were reviewed with facility staff as part of the inspection process.
|
Plan of Correction
By March 31, 2021, the facility director will develop an annual training plan for clinical staff members. By April 7, 2021, the facility director will review the training plan with counselors and inform them of the annual training requirements. The facility director will monitor each counselor's individual training plan quarterly and verify they are on track to complete at least 25 hours of training each year in the suggested topic areas. The senior area manager will monitor the process for six months or until compliance is achieved and sustained. |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
|
Observations
Based on a review of the facility's staffing report, the facility failed to ensure that their inpatient nonhospital treatment and rehabilitation level of care, serving adult clients, shall have one full time equivalent (FTE) counselor for every eight clients. The FTE is determined by the facility-submitted staffing report and the formula is done by dividing the total number of hours counselors devoted to their clients (165) by the project workweek (40) =4.125. Then, to obtain the overall ratio, the total number of clients on the residential caseload (50) is divided by the FTE (4.125) = 12.12 or 13:1. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The facility has been actively recruiting since February 2021 to backfill vacant positions. GEO's Corporate Human Resources recruiters are assisting with identifying potential candidates, and they have posted the job position on recruitment websites in an effort to reach a broad applicant pool. Once both counselor positions are filled, the program will be in compliance with the required client-to-counselor ratio. The facility director will monitor the process for 60 days or until compliance is achieved and sustained. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
|
Observations
During a physical plant inspection conducted on February 23, 2021, the facility failed to ventilate toilet and washrooms by exhaust fan or window. The exhaust fan located in the central men's bathroom was not operative at the time of inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By March 19, 2021, the facility director will order a replacement exhaust fan for the central men's bathroom. The facility director will verify the exhaust fan has been installed and works properly by March 31, 2021. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
|
Observations
Based on a physical plant inspection, conducted on the morning of February 23, 2021, the facility failed to ensure that frozen food was kept at or below 0The freezer, which was located in the kitchen, registered a temperature of 11findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By March 31, 2021, the facility director will work with the corporate office to obtain a vendor to repair or replace the freezer. The senior area manager will monitor the process for 30 days or until compliance is achieved and sustained. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all shifts are trained to perform assigned tasks during emergencies in one of one applicable personnel records reviewed. Employee #1 was hired as a counselor on May 12,2020. Emergency preparedness training was not provided as of the date of inspection. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By March 26, 2021, the facility director will complete emergency preparedness training, including fire safety procedures, with all employees. Beginning March 29, 2021, all newly hired employees will complete emergency preparedness training within 30 days of hire. The senior area manager will monitor the process for 90 days or until compliance is achieved and sustained. |
709.28 (c) 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.
|
Observations
Based on a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.Client # 4 was admitted on July 14, 2020 and discharged on August 27, 2020. There was documentation of disclosures to a government agency during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By March 19, 2021, the facility director will provide training to clinical staff members regarding client confidentiality and the process for obtaining written and informed consent from clients to release information. Beginning March 22, 2021, the facility director will complete weekly clinical chart reviews to verify consent to release information forms have been completed as required. The senior area manager will monitor the process for 90 days or until compliance is achieved and sustained. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
|
Observations
Based on a review of client records, the facility failed to keep release of information forms for the disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in seven of seven client records reviewed.Client # 1 was admitted on August 26, 2020 and discharged on October 23, 2020. A release of information form to a government agency was signed and dated by the client on August 26, 2020 allowed for the release of medication list, list of allergies, treatment plans, assessments, immunization record, progress reports, and most recent discharge plan, all of which exceeds the limits established by 4 Pa. Code 255.5.Client # 2 was admitted on September 14, 2020 and discharged on October 28, 2020. A release of information form to a government agency was signed and dated by the client on September 14, 2020 allowed for the release of medication list, list of allergies, treatment plans, assessments, immunization record, progress reports, and most recent discharge plan, all of which exceeds the limits established by 4 Pa. Code 255.5.Client # 3 was admitted on October 7, 2020 and discharged on December 18, 2020. A release of information form to a government agency was signed and dated by the client on October 7, 2020 allowed for the release of medication list, list of allergies, treatment plans, assessments, immunization record, progress reports, and most recent discharge plan, all of which exceeds the limits established by 4 Pa. Code 255.5.Client # 4 was admitted on July 14, 2020 and discharged on August 27, 2020. A release of information form to a government agency was signed and dated by the client on July 14, 2020 allowed for the release of medication list, list of allergies, treatment plans, assessments, immunization record, progress reports, and most recent discharge plan, all of which exceeds the limits established by 4 Pa. Code 255.5.Client # 5 was admitted on January 20, 2021 and was still active at the time of inspection. A release of information form to a government agency was signed and dated by the client on January 20, 2021 allowed for the release of medication list, list of allergies, treatment plans, assessments, immunization record, progress reports, and most recent discharge plan, all of which exceeds the limits established by 4 Pa. Code 255.5.Client # 6 was admitted on January 20, 2021 and was still active at the time of inspection. A release of information form to a government agency was signed and dated by the client on January 20, 2021 allowed for the release of medication list, list of allergies, treatment plans, assessments, immunization record, progress reports, and most recent discharge plan, all of which exceeds the limits established by 4 Pa. Code 255.5.Client # 7 was admitted on January 13, 2021 and was still active at the time of inspection. A release of information form to a government agency was signed and dated by the client on January 13, 2021 allowed for the release of medication list, list of allergies, treatment plans, assessments, immunization record, progress reports, and most recent discharge plan, all of which exceeds the limits established by 4 Pa. Code 255.5.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By March 15, 2021, the facility director will revise the Authorization to Disclose Health Information form in order to meet the 4 PA. Code 255.5 criteria. By March 19, 2021, the facility director will provide training to clinical staff members regarding client confidentiality, to include the limits set forth in 4 PA Code 255.5, and the process for obtaining written and informed consent from clients to release information. Beginning March 22, 2021, the facility director will complete weekly clinical chart reviews to verify consent to release information forms have been completed as required. The senior area manager will monitor the process for 90 days or until compliance is achieved and sustained |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent was offered to the client in seven of seven client records reviewed.Client # 1 was admitted on August 26, 2020 and discharged on October 23, 2020. A release of information form to a government agency was signed and dated by the client on August 26, 2020 did not indicate that a copy was offered to the client. Client # 2 was admitted on September 14, 2020 and discharged on October 28, 2020. A release of information form to a government agency was signed and dated by the client on September 14, 2020 did not indicate that a copy was offered to the client. Client # 3 was admitted on October 7, 2020 and discharged on December 18, 2020. A release of information form to a government agency was signed and dated by the client on October 7, 2020 did not indicate that a copy was offered to the client.Client # 4 was admitted on July 14, 2020 and discharged on August 27, 2020. A release of information form to a government agency was signed and dated by the client on July 14, 2020 did not indicate that a copy was offered to the client.Client # 5 was admitted on January 20, 2021 and was still active at the time of inspection. A release of information form to a government agency was signed and dated by the client on January 20, 2021 did not indicate that a copy was offered to the client.Client # 6 was admitted on January 20, 2021 and was still active at the time of inspection. A release of information form to a government agency was signed and dated by the client on January 20, 2021 did not indicate that a copy was offered to the client.Client # 7 was admitted on January 13, 2021 and was still active at the time of inspection. A release of information form to a government agency was signed and dated by the client on January 13, 2021 did not indicate that a copy was offered to the client. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By March 15, 2021, the facility director will revise the "Authorization to Disclose Health Information" form in order to meet the 4 PA. Code 255.5 criteria. By March 19, 2021, the facility director will provide training to clinical staff members regarding client confidentiality, including verification that the client was offered a copy. Beginning March 22, 2021, the facility director will complete weekly clinical chart reviews to verify that the clients have been offered a copy of the consent to release form. The senior area manager will monitor the process for 90 days or until compliance is achieved and sustained. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
|
Observations
Based on a review of medication records, the facility failed to ensure that there was proper documentation of the administration of medication, including documenting missed doses, in two of seven client records reviewed. Client # 1 was admitted on August 26, 2020 and discharged on October 23, 2020. The client was prescribed a medication to be administered one time a day; however, there were several days documented in the medication record log, throughout the client's treatment episode, of doses that were missed and a refusal/reason for the missed doses were not documented. Client # 3 was admitted on October 7, 2020 and discharged on December 18, 2020. The client was prescribed a medication to be administered one time a day; however, there were several days documented in the medication record log, throughout the client's treatment episode, of doses that were missed and a refusal/reason for the missed doses were not documented. These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By March 15, 2021, the operations director will revise the "Medication Control" form to include documentation of the reasons for missed doses. Beginning March 15, 2021, the operations director will assign a security staff member to audit medication control forms weekly to verify that the reasons for missed medication doses have been documented. The facility director will monitor the process for 90 days or until compliance is achieved and sustained. |
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.
|
Observations
Based on the review of the facility's unusual incident report logs and fire drill logs, the facility failed to notify the Department within 3 business days of an event at the facility requiring the presence of police, fire, or ambulance personnel.On June 7, 2020, the fire department was called to the facility and the building was evacuated; however, there was no documentation that this incident was reported to the Department with 3 business days. On December 1, 2020, an emergency medical team was called to the facility for client #3, who was then transported to the hospital; however, there was no documentation that this incident was reported to the Department within 3 business days.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By April 1, 2021, the facility director will complete a refresher training on the facility's "Unusual Incident Reporting" policy with clinical and management employees. Within three business days following an unusual incident, the facility director will verify that an unusual incident report was submitted to the Department. The senior area manager will monitor the process for 90 days or until compliance is achieved and sustained. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.Client # 2 was admitted on September 14, 2020 and discharged on October 28, 2020. The treatment plan update completed on October 19, 2020 indicated 7.5 hours of group therapy per week, however, there was no documentation in the client record that group counseling services occurred during the week of October 19, 2020 through October 24, 2020. Client # 3 was admitted on October 7, 2020 and discharged on December 18, 2020. The treatment plan update completed on October 15, 2020 indicated .5 hours of individual counseling sessions, however, there was no documentation in the client record that individual counseling services occurred during the week of October 18, 2020 through October 24, 2020. Client # 5 was admitted on January 20, 2021 and was still active at the time of inspection. The comprehensive treatment plan, completed on January 27, 2021, indicated 1.5 hours of groups 5x weekly, however; there was no documentation in the client record that group counseling services occurred during the week of January 21, 2021 through January 29, 2021.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By March 19, 2021, the facility director will provide refresher training to clinical staff members regarding weekly clinical service requirements and the clinical documentation process. Beginning March 22, 2021, the facility director will complete weekly clinical chart reviews to verify treatment services have been documented as required. The senior area manager will monitor the process for 90 days or until compliance is achieved and sustained. |