INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 17, 2024, 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:
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Plan of Correction
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704.3(a) LICENSURE Relapse Policy
704.3. General requirements for projects.
(a) The project shall develop a written policy to address relapse of recovering clinical personnel.
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Observations
Based on a review of the project ' s policy and procedure manual, the project failed to develop a written policy to address the relapse of recovery clinical personnel, which is to include how the project will address the discipline of nonrecovery employees who abuse alcohol and other drugs.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
704.3. General requirements for projects. (a ) The project shall develop a written policy to address relapse of recovering clinical personnel. On 1/07/2025, the Facility Director located GEO Corporate policy that addresses the relapse of recovery clinical personnel, which included how GEO Corporate will address the discipline of nonrecovery employees who abuse alcohol and other drugs. Facility Director will ensure that all policies are maintained with yearly review.
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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.
When tested, the water in the bathroom utilized by rooms 5, 6 and 7 was 130.9 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
705.6. Bathroom. The resident facility shall: (3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F. On 12/18/2024, Maintenance tech turned down amount of gas flow form gas valve on hot water heater to 115 degrees Fahrenheit. Then checked water temperature at sink using infrared thermometer. Maintenance tech will check and inspect hot water heater on a weekly basis. |
709.24 (a) (2) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(2) Identification of the treatment models and practices utilized by the project.
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Observations
Based on the review of the project ' s policy and procedure manual, the project failed to develop a written plan for the coordination of client treatment and rehabilitation services which included identification of the treatment models and practices utilized by the project.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.24. Treatment/rehabilitation management. (a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but it not limited to: (2) Identification of the treatment models and practices utilized by the project. On 1/07/2025, the Facility Director updated ADAPPT local policy procedure Manuel which implements a written plan for the coordination of client treatment and rehabilitation services. This policy included the identification of the treatment models and practices utilized by the project. Facility Director will ensure that all policies are maintained with yearly review. |
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
Based on the review of client records, the project failed to obtain an 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 August 21, 2024 and was discharged on October 21, 2024. Facility staff members communicated with two separate mental health providers on August 23, 2024, August 28, 2024 and September 19, 2024; however, there were no release of information forms signed by the client prior to disclosures.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
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.
On 1/07/2025, the Clinical Director had a staff meeting to provide refresher training which included the requirement of obtaining informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made. Clinical Director will ensure that all consent forms are maintained in clinical files by completing her weekly and monthly audit of client charts. |
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 the review of client records, the project failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made to in one of seven records reviewed.
Client #5 was admitted on May 15, 2024 and was discharged on July 15, 2024. A release of information form, signed by the client on May 16, 2024, did not specify the name of the person, agency or organization to whom disclosure is to be made.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
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.
On 1/07/2025, the Clinical Director had a staff meeting to provide refresher training which included the requirement of obtaining informed and voluntary consent from the client for the disclosure of information contained in the client record that included the name of the person, agency or organization to whom disclosures will be made. Clinical Director will ensure that all consent forms are maintained in clinical files by completing her weekly and monthly audit of client charts. |
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 the review of client records, the project failed to offer a copy of the release of information forms in one of seven client records reviewed.
Client #5 was admitted on May 15, 2024 and was discharged on July 15, 2024. There was no documentation that the client was offered a copy of the release of information form for a primary care physician, signed and dated by the client on June 13, 2024.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
A staff meeting was held on 1/7/25 and it was discussed that all releases must be either accepted or declined and checked by the client. This will be ongoing. Facility Director will continue to check all charts to ensure that all releases have been offered a copy to the client and it will be checked as such. |
709.34 (a) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(2) Selling or use of illicit drugs on the premises.
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Observations
Based on the review of the project ' s policy and procedure manual, the project failed to develop and implement policies and procedures to respond to an unusual incident involving the selling or use of illicit drugs on the premises.
These findings were reviewed with project staff during the licensing process.
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Plan of Correction
709.34. Reporting of unusual incidents. (a) The project shall develop and implement policies and procedures to respond to the following unusual incidents: (2) Selling or use of illicit drugs on the premises. The Facility Director will create ADAPPT local policy procedure Manuel to implement policy procedures to respond to the following unusual incidents: (2) Selling or use of illicit drugs on the premises. Facility Director is projected to complete by 1/24/2025 and maintain yearly review. |