INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 19, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. 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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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to document that it notified the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of one client record.
Seven clients records were reviewed on February 19, 2019. One client record, # 5, required notification of termination.
Client # 5 was involuntarily discharged on December 30, 2018. There was no documentation provided that the client was notified, in writing, of the decision to terminate his treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The project shall notify a client in writing of a decision to involuntarily terminate treatment including the reason(s) for the involuntary termination. A copy of this required notification shall be maintained in the client file.
The Director shall review the current licensing non-compliance with the program counselors and the requirement/corrective action of DDAP licensing. The counselors shall be responsible to notify the client in writing if/when there is a decision to involuntarily terminate their treatment. A copy of the involuntary discharge form with the reason(s) for the termination shall be shared with and provided to the client as part of the termination process. As part of the involuntary termination process, the client will be asked to sign and date the form verifying this standard has been met. If a client refuses to sign the form, the counselor shall indicate this refusal in the client chart. A copy of this form shall be maintained in the client chart. This process shall become effective April 1, 2019. It shall be the responsibility of the program director to randomly review charts monthly,from clients involuntarily discharged to insure compliance is achieved. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
The facility failed to document a physical examination of the client in two of seven client records.
Seven client records were reviewed on February 19, 2019. All seven required documentation of a physical examination.
Client record # 1 was missing documentation of a physical examination.
Client record # 4 documented a physical examination that was completed by a nurse.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients admitted into the facility shall have a physical exam at admission signed by a physician. It shall be the responsibility of the intake/counselors to insure receipt of this document as part of the intake process.
The Director shall review with the intake/counselors the current non-compliance and steps to reach compliance with this DDAP licensing standard by April 10, 2019.
It shall be the responsibility of the Director on a weekly basis to review admissions for that week to insure compliance with the DDAP licensing standard by April 11, 2019.
A copy of a physician signed physical exam form shall be maintained in the client chart. This process shall be effective April 12, 2019.
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