INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 6, 2024 and February 7, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Salvation Army Harbor Light Center 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(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:
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Observations
Based on a review of facility records, the facility failed to ensure the project director developed 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 an annual evaluation of the overall training plan.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 6, 2023 annual licensing inspection.
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Plan of Correction
Training Plans will now be completed by direct supervisors on a fiscal year basis. Every employee will have an active training plan before June 15 of every year. These training plans will then be turned in the Executive Director before June 28 of every year. The training plans will then be filed in to every employee's personal file by July 1 every year.
The overall training evaluation will be completed, by Clinical Supervisor and Executive Director by July 1 every year. This will encompass the outcomes of individual staff training plans, time constraints, and any training needs for the next fiscal year.
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705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on inspection of the physical plant, the facility failed to ensure all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company.
During a walk-through of the facility, a fire extinguisher was found with an inspection tag indicating the last inspection of the fire extinguisher being completed in January, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire extinguisher that was found to be out of compliance has already been inspected and replaced.
Facilities manager will be in charge of annual fire extinguisher audits. These will continue to occur in January of every year. Facilities manager will relay any delays in inspection or concerns to executive director by February 15 every year.
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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of facility records, the facility failed to ensure that the project director prepared, annually updated and signed a written manual delineating project policies and procedures.
The last signed update to the written manual was dated January, 2022. No update was documented for the years of 2023 or 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Administrative Secretary and Clinical Supervisor will review policy and procedure annually in December. All changes will be made between December and January. By January 15 Executive Director will review any changes made. By January 31 the manual update notice will be sent to all staff with a mandatory sign and return date of February 15.
Signed notices will be placed in employee file and the general notice of update, signed by Executive Director, will be placed in the policy and procedure manual.
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709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client which includes name of the person, agency, or organization to whom disclosure is made in one of seven records.
Client #2 was admitted to the inpatient level of care of December 18, 2023 and was active at the time of review. Client #2 ' s record contained a release of information dated December 18, 2023 that did not contain the name of the person, agency, or organization to whom disclosure is made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapists will complete the DDAP confidentiality training again to be up to date with current policies and procedures.
As Harbor Light transitions to an electronic medical record the software will not allow consents to be completed without all sections completed.
In the current time, beginning April 1, behavioral technician will complete all consents and present them to therapist for review before adding them to the chart or sending to any outside providers.
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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 obtain an informed and voluntary consent from the client which includes purpose of disclosure in six of seven records.
Client #1 was admitted to the inpatient level of care of October 17, 2023 and was active at the time of review. Client #1 ' s record contained a release of information dated October 17, 2023 that did not indicate a purpose of disclosure.
Client #3 was admitted to the inpatient level of care of November 9, 2023 and was active at the time of review. Client #3 ' s record contained a release of information dated November 9, 2023 that did not indicate a purpose of disclosure.
Client #4 was admitted to the inpatient level of care of August 3, 2023 and was discharged November 7, 2023. Client #4 ' s record contained a release of information dated August 3, 2023 that did not indicate a purpose of disclosure.
Client #5 was admitted to the inpatient level of care of October 27, 2023 and was discharged January 25, 2024. Client #5 ' s record contained a release of information dated October 27, 2023 that did not indicate a purpose of disclosure.
Client #6 was admitted to the inpatient level of care of August 31, 2023 and was discharged January 29, 2024. Client #6 ' s record contained a release of information dated August 31, 2023 that did not indicate a purpose of disclosure.
Client #7 was admitted to the inpatient level of care of May 26, 2023 and was discharged October 31, 2023. Client #7 ' s record contained a release of information dated May 26, 2023 that did not indicate a purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapists will complete the DDAP confidentiality training again to be up to date with current policies and procedures.
As Harbor Light transitions to an electronic medical record the software will not allow consents to be completed without all sections completed.
In the current time, beginning April 1, behavioral technician will complete all consents and present them to therapist for review before adding them to the chart or sending to any outside providers.
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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.
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Observations
Based on a review of client records, the facility failed to ensure a copy of client consent was offered to the client in five of seven records.
Client #1 was admitted to the inpatient level of care of October 17, 2023 and was active at the time of review. Client #1 ' s record contained a release of information dated October 17, 2023. The release of information form contained spaces to indicate if a copy of the release was offered to the client. No indication was made on the release of information form that a copy of the release of information was offered.
Client #3 was admitted to the inpatient level of care of November 9, 2023 and was active at the time of review. Client #3 ' s record contained a release of information dated November 9, 2023. The release of information form contained spaces to indicate if a copy of the release was offered to the client. No indication was made on the release of information form that a copy of the release of information was offered.
Client #4 was admitted to the inpatient level of care of August 3, 2023 and was discharged November 7, 2023. Client #4 ' s record contained a release of information dated August 3, 2023. The release of information form contained spaces to indicate if a copy of the release was offered to the client. No indication was made on the release of information form that a copy of the release of information was offered.
Client #5 was admitted to the inpatient level of care of October 27, 2023 and was discharged January 25, 2024. Client #5 ' s record contained a release of information dated October 27, 2023. The release of information form contained spaces to indicate if a copy of the release was offered to the client. No indication was made on the release of information form that a copy of the release of information was offered.
Client #6 was admitted to the inpatient level of care of August 31, 2023 and was discharged January 29, 2024. Client #6 ' s record contained a release of information dated August 31, 2023. The release of information form contained spaces to indicate if a copy of the release was offered to the client. No indication was made on the release of information form that a copy of the release of information was offered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Therapists will complete the DDAP confidentiality training again to be up to date with current policies and procedures.
As Harbor Light transitions to an electronic medical record the software will not allow consents to be completed without all sections completed.
In the current time, beginning April 1, behavioral technician will complete all consents and present them to therapist for review before adding them to the chart or sending to any outside providers.
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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 facility records, the facility failed to have and implement a written policy and procedure regarding medications used by clients which includes inspection of storage areas that ensures compliance with State and Federal laws and program policy.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of May 1st 2024, The Harbor Light Center is employing a Health Care Navigator (HCN) that is an RN. The HCN will complete the policy on medical control inspections. HCN will also complete the inspection monthly. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of facility records, the facility failed to have and implement a written policy and procedure regarding medications used by clients which includes methods for control and accountability of drugs, including the programs system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of May 1st 2024, The Harbor Light Center is employing a Health Care Navigator (HCN) that is an RN. The HCN will write and complete a policy of the medication control regarding methods of control, accountability, and record keeping. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of facility records, the facility failed to have and implement a written policy and procedure regarding medications used by clients which includes medication errors and drug reactions shall be recorded in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of May 1st 2024, The Harbor Light Center is employing a Health Care Navigator (HCN) that is an RN. The HCN will complete a policy that outlines the procedures of medication errors, drug reactions, and how to report/record these. |
709.52(a) LICENSURE Individual TX and REHAB Plan
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:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within the written policy and procedure time frame in three of six records.
Facility policy and procedure states a comprehensive treatment plan is to be completed within 72 hours of admission.
Client #1 was admitted to the inpatient level of care on October 17, 2023 and was active at the time of review. The first comprehensive treatment plan was due no later than October 20, 2023, but was completed October 24, 2023.
Client #4 was admitted to the inpatient level of care on August 3, 2023 and was discharged November 7, 2023. The first comprehensive treatment plan was due no later than August 6, 2023, but was completed August 17, 2023.
Client #6 was admitted to the inpatient level of care on August 31, 2023 and was discharged January 29, 2024. The first comprehensive treatment plan was due no later than September 3, 2023, but was completed September 21, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The HLC is operating treatment plans being completed within the first 21 days of treatment, and then updates completed every 30 days after or if a major change in progress or treatment has occurred.
The current Harbor Light policy does not match our procedures.
The Harbor Light policy will be updated to reflect current procedures and happenings by April 1st, 2024.
Clinical Meeting with therapists is held every Thursday. Any treatment plans for that week will be brought to the clinical meeting for review and signature. Any that are due and not presented will result in verbal warning with progressive discipline from there from repeat offenses. Clinical Supervisor will review due treatment plans.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure treatment and rehabilitation plans were reviewed and updated at least every 30 days in three of six records.
Client #1 was admitted to the inpatient level of care of October 17, 2023 and was active at the time of review. Client #1 ' s record contained a treatment plan dated October 24, 2023. A treatment plan update was due no later than November 24, 2023. The next treatment plan update for Client #1 was dated November 30, 2023.
Client #4 was admitted to the inpatient level of care of August 3, 2023 and was discharged November 7, 2023. Client #4 ' s record contained a treatment plan dated September 13, 2023. A treatment plan update was due no later than October 13, 2023. The next treatment plan update for Client #4 was dated October 16, 2023.
Client #6 was admitted to the inpatient level of care of August 31, 2023 and was discharged January 29, 2024. Client #6 ' s record contained a treatment plan dated November 23, 2023. A treatment plan update was due no later than December 23, 2023. No further treatment plan updates were found.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Harbor Light Center is transitioning to an electronic health record. The EHR will put the treatment plan due date on a calendar and send reminders to update. It will also notify therapist if the treatment plan is late.
In the present time, as of April 1st, therapists will put treatment plan dates on the Microsoft Calendar and share with supervisor. Supervisor will send weekly reminders of the documents due for the week. Clinical Supervisor is completing weekly chart inspections to ensure that documents are timely.
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709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to ensure that the client record included a record of services provided in seven of seven records.
Client records #1, 2, 3, 4, 5, 6, and 7 did not include documentation of a record of services provided.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 6, 2023 annual licensing inspection.
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Plan of Correction
Harbor Light Center is transitioning to an EHR. The EHR will complete a record of services for every document in the client chart.
In the present time all therapists will complete a record of service for the client charts beginning April 1st. The records of service will encompass group notes, individual notes, and case management notes. These will be audited during weekly chart checks completed by Clinical Supervisor.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to ensure there is a complete client record, which includes case consultation notes, in six of seven records.
Facility policy and procedure states that a case consultation should occur no less than every thirty days.
Client #1 was admitted to the inpatient level of care of October 17, 2023 and was active at the time of review. Client #1 ' s record contained a case consultation note dated October 18, 2023. A case consultation note was due no later than November 18, 2023. No further case consultation notes were found in the client record.
Client #2 was admitted to the inpatient level of care of December 18, 2023 and was active at the time of review. Client #2 ' s record contained a case consultation note dated December 25, 2023. A case consultation note was due no later than January 25, 2024. No further case consultation notes were found in the client record.
Client #3 was admitted to the inpatient level of care of November 9, 2023 and was active at the time of review. A case consultation note was due no later than December 9, 2023. No case consultation notes were found in the client record.
Client #4 was admitted to the inpatient level of care of August 3, 2023 and was discharged November 7, 2023. Client #4 ' s record contained a case consultation note dated August 10, 2023. A case consultation note was due no later than September 10, 2023. The next case consultation note did not occur until November 1, 2023.
Client #5 was admitted to the inpatient level of care of October 27, 2023 and was discharged January 25, 2024. A case consultation note was due no later than November 27, 2023. No case consultation notes were found in the client record.
Client #6 was admitted to the inpatient level of care of August 31, 2023 and was discharged January 29, 2024. Client #6 ' s record contained a case consultation note dated September 2, 2023. A case consultation note was due no later than October 2, 2023. No further case consultation notes were found in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Harbor Light Center completes a case consult within 7 days of admission to the program. HLC also completes updates every 90 days. The current policy does not reflect this procedure. Clinical Supervisor will update the policy to reflect current procedures by April 1st, 2024.
All new admits' case consults will be reviewed on the weekly Thursday clinical meeting. Case consults from persons admitted within the previous 7 days will be mandatory to be reviewed.
Therapists will present their 90 day reviews during weekly clinical meeting when due. Clinical Supervisor will weekly review the roster to ensure intake dates and how long someone has been inthe program. |