INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Tradition House, was found to not 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
The facility failed to provide a sufficient number of staff persons trained in CPR certification and first aid training so that at least one person trained in these skills is onsite during the project's hours of operation.
The Non-Hospital Rehabilitation facility is operable twenty-four hours per day/seven days per week.
Employee #5 was hired as a Behavioral Health Tech on 5/7/2017 and does not have First Aid and CPR Certification. Employee #5 was scheduled to work 8am to 4 pm alone on the following dates: May 27, 2018, June 1, 2018, June 3, 2018, June 7, 2018, and June 10, 2018.
The facility failed to have sufficient coverage.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will ensure that all shifts are covered by at least one employee who is CPR/first aid certified. Program Director and BH Tech Supervisor will monitor compliance via obtaining a copy of all employees CPR/first aid cards and comparing these to the staff schedule on a monthly basis. Any employee who is due for CPR/first aid recertification will be scheduled by BH Tech Supervisor and reminded of the training date. BH Tech Supervisor will follow up with Human Resources following training date to ensure employee completed. Employee #5 is no longer employed at our facility. Moving forward, Program Director and BH Tech Supervisor will ensure all staff trainings are completed in timely manner. |
705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
The facility did not maintain all furnishings in good repair in the living room that was used for clients, their families or guests.
The black couch in the living room was not in good repair and could cause injury to clients, their families or guests.
These findings were reviewed with the staff during the licensing process.
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Plan of Correction
The black couch was removed from the facility on 7/21/18. New furnishing were purchased on 8/1/18. Program Director and Risk Committee will monitor furnishing during monthly facility checks to ensure they are in good repair. Maintenance will be immediately notified if issues arise, to ensure safety of clients, families, and guests. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
The facility failed to maintain the outside fire escape with a well-secured handrail. The outside fire escape handrail was loose.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility Maintenance repaired the fire escape handrail on 7/20/2018 to ensure safety. Facility Maintenance, Program Manager, and Risk Committee will monitor all aspects of the outside escape route during their monthly facility checks to ensure all parts remain well-secured and safe. |
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.
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Observations
The facility failed to obtain release forms for funding sources within the parameters of 255.5 in seven out of seven client records.
Client #1 was admitted on April 11, 2018 and was still active at the time of the survey. A release of records to VBH-Beacon/Washington was signed by the client on April 11, 2018 for the five points outlined in 255.5 plus general progress updates.
Client #2 was admitted on May 1, 2018 and was still active at the time of the survey. A release for records to Magellan Behavioral Helath was signed by the client on May 1, 2018 for the five points outlined in 255.5 plus general progress updates.
Client #3 was admitted on May 29, 2018 and still active at the time of the survey. A release for records to CCBHO was signed by the client on May 29, 2018 for the five points outlined in 255.5 plus general progress updates.
Client # 4 was admitted on December 22, 2017 and was discharged on April 18, 2018. Releases for records to Lebanon Co Assistance Office and Performcare were signed by the client on December 22, 2018 for the five points outlined in 255.5 plus general progress updates.
Client #5 was admitted on February 21, 2018 and was discharged on May 21, 2018. A release for information to CCBHO was signed by the client on February 21, 2018 for the five points outlined in 255.5 plus general progress updates.
Client #6 was admitted on December 1, 2017and was discharged on April 10, 2018. A release for information to CCBHO was signed by the client on December 1, 2017 for CCBHO for the five points outlined in 255.5 plus general progress updates.
Client # 7 was admitted January 11, 2018 and was discharged on April 4, 2018. A release of information for Magellan was signed by the client on January 11, 2018 for the five points outlined in 255.5 plus general progress updates, psychological assessments, psychiatric evaluations, medical history and physical and treatment progress updates.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Manager conducted an in-house training with clinical and administrative staff on 8/1/18 pertaining to consents. Reviewed parameters of 255.5.Program Manager and Lead Counselor will review consents during monthly clinical chart audits and monitor accuracy. Lead Counselor and Program Director will individually address any ongoing compliance concerns during monthly supervision. Consents for current clients will be updated as needed by August 31,2018. |
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
The facility failed to update treatment plans within thirty days in three out of seven clients.
Client #1 was admitted on April 11, 2018 and was active at the time of inspection. A treatment plan was completed on June 8, 2018 and the next was due no later than July 8, 2018; however, it was not completed until July 18, 2018.
Client # 6 was admitted on December 1, 2017 and was discharged on April 10, 2018. A treatment plan was completed on February 27, 2018 and the next was due no later than March 27, 2018; however one was never completed before discharge on April 10, 2018.
Client #7 was admitted on January 11, 2018 and was discharged on April 11, 2018. A treatment plan was completed on March 8, 2018 and the next was due no later than April 8, 2018; however one was never completed before discharge on April 11, 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Manager conducted an in-house treatment plan training for all clinical staff on 8/1/2018. All current clinical staff were present. Reviewed all regulations and timeframes required. Program Director and Lead Counselor will monitor compliance during monthly chart audits. Next chat audit will be conducted by August 31,2018. Program Director and Lead Counselor will address any ongoing compliance issues individually during monthly clinical supervision. |
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.
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Observations
The facility failed to provide group counseling at least twice weekly in 6 out of 7 client records.
Client #2 did not receive two group counseling sessions during the weeks of May 6, 2018, May 13, 2018, May 20, 2018, June 10, 2018, June 24, 2018, July 1, 2018 and July 8, 2018.
Client #3 did not receive two group counseling sessions during the weeks of June 10, 2018, June 25,2018 and July 1, 2018.
Client #4 did not receive two group counseling sessions during the weeks of December 24, 2017, December 31, 2017, January 7, 2018, January 14, 2018, January 21, 2018, January 28, 2018, February 11, 2018, March 4, 2018, March 11, 2018, March 25, 2018 and April 8, 2018.
Client # 5 did not receive two group counseling sessions during the weeks of March 4, 2018, March 11, 2018, March 18, 2018, March 25, 2018, April 1, 2018, April 8, 2018, April 15, 2018, April 22, 2018, May 6, 2018 and May 13, 2018.
Client #6 did not have two group counseling sessions during the weeks of January 7, 2018, February 11, 2018, February 25, 2018, March 4, 2018, March 11, 2018, March 18, 2018, March 25, 2018 and April 1, 2018.
Client #7 did not have two group counseling sessions during the weeks of January 21, 2018, January 28, 2018, February 4, 2018, February 11, 2018, February 18, 2018, March 4, 2018, March 11, 2018, March 18, 2018, March 25, 2018 and April 1, 2018.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director and Lead Counselor will ensure that group therapy is provided weekly and individual sessions are provided bi-weekly, via monthly chart audits. Clinicians will document reasons if a client misses group due to being at work or dr apt. etc. indicating reason for missed group that week. If client maintains regular employment, clinician will document group being provided once a week on treatment plan. Lead Counselor will review any ongoing issues with clinicians during monthly supervision. |