INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 14, 2021 through September 15, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, Inc. 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that clinical supervisors and lead counselors who have not functioned for 2 years as a supervisor in the provision of clinical services completed a Department-approved core curriculum in clinical supervision.
Employee # 2 was hired as a clinical supervisor on February 10, 2021 and did not have clinical supervision experience prior to being hired. There was no documentation of a Department-approved curriculum in clinical supervision training in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Manager and/or designee will ensure that the Clinical Director attends the core curriculum for clinical supervision.
They will find out when and where the training is being held and sign the Clinical Director up for the training and ensure that it is paid for by Self Help Movement. |
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.
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Observations
Based on a review of the facility-submitted Staffing Requirements Facility Summary Report, the facility failed to ensure that their Inpatient nonhospital treatment and rehabilitation licensed activity, which is serving adult clients, shall have one Full Time Equivalent (FTE) counselor for every eight clients.
The FTE is determined by dividing the total number of combined counselor hours devoted to clients by the facility's standard workweek. Then, to obtain the activity ratio, the total number of active clients is divided by the FTE.
The FTE calculation is as follows: 400/40 = 10 (FTE); 90/10 = 9, which equals to a FTE counselor/client ratio of 9:1.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Self Help Movement has had some changes in its staffing in the past few months. The Human Resources Manager is in the process of hiring more clinical staff to ensure that client/ counselor ratios are in compliance with 1:8.
This should be achieved by 12/31/21.
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705.4 (2) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(2) Maintain counseling areas with furnishings which are in good repair.
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Observations
Based on a physical plant inspection conducted on September 15, 2021, the facility failed to maintain counseling areas with furnishings that are in good repair. The basement group rooms-B, D, E, G, the counselor office 1-C-located in the basement, and a counselor's office -located in the back administration area all had chairs that were ripped or torn.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Building and Maintenance has ordered new chairs to be placed in the basement group rooms and counselor's offices. The Director of Building and Maintenance will ensure that chairs will be replaced as soon as the shipment comes in. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection conducted on September 15, 2021, the facility failed to ensure that each bedroom had a bed with a solid foundation and a fire retardant mattress in good repair. The mattress located in room # 18, located on the first-floor non-quarantined residential area, had a large tear on the top of the mattress.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Building and Maintenance has replaced the ripped mattress. He will ensure that all rooms
The Director of Building and Maintenance has replaced the ripped mattress. Self Help Movement has in place maintenance request slips for the clients and/or supervisor on duty to fill out and to be placed in the maintenance book. This book is checked every day by the maintenance designee to ensure that the rooms and furnishings are in good repair.
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705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection conducted on September 15, 2021, the facility failed to maintain bathrooms in a functional, clean and sanitary manner at all times.
The handicap bathroom, located in the basement, had a sink faucet that was loose and appeared to have mildew around the base of the faucet. Additionally, both the community bathroom, located on the first-floor of the non-quarantined residential area, and the community bathroom, located on the second-floor phase #2 area, had sink faucets that were actively leaking.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Building and Maintenance checked all mentioned sink faucets and with a little bit of pressure the faucets stopped dripping.
If/when the faucets start to leak again the Director of Building and Maintenance will ensure that the designee will change the washers on the faucets.
The handicap bathroom faucet only had discoloration around the faucet. This was scrubbed and sanitized.
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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 a physical plant inspection conducted on September 15, 2021, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company. The fire extinguisher, located on the third-floor hallway of the transitional living area, had an inspection tag with the last inspection date being October 2004.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
The Director of Building and Maintenance will ensure that all fire extinguishers are inspected on a monthly basis. If the extinguisher is found to be inoperable it shall be replaced or repaired within 48 hours of the time it was found.
The fire extinguisher was removed and was replaced immediately with an operable fire extinguisher. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility's July 2020 through August 2021 fire drill logs, the facility failed to identify, on their drill log, the exit route used and the number of persons in the facility at the time of the drill.
The fire drill logs, for the drills conducted during the months of November 2020, December 2020, January 2021, February 2021, May 2021, and June 2021, failed to document the exit route used and the number of persons in the facility at the time of the drill. Additionally, the fire drill log, for the drill conducted during the month of July 2021, failed to document the exit route used.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Building and Maintenance will ensure that all fire drill logs are completed in their entirety with all required information for all fire drills. |
705.10 (d) (7) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(7) Conduct fire drills on different days of the week, at different times of the day and night and on different staffing shifts.
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Observations
Based on a review of the July 2020 through August 2021 fire drill logs, the facility failed to conduct fire drills during different days of the week and different staffing shifts.
The facility is a residential facility and provides services 24 hours a day/7 days a week; however, there were no fire drills conducted on Saturday or Sunday during the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Building and Maintenance will ensure that fire drills are also conducted on weekends at different times of the day and night and on different shifts. |
709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on a physical plant inspection conducted on September 15, 2021, the facility failed to secure hard copy client records within locked storage containers. There were client records in open boxes located in the locked chart room; however, the chart room also serves as an access to two additional offices.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director of Building and Maintenance will ensure that the client records in the chart room that were in open boxes will be taken out of the open boxes and placed in a locked storage cabinet. |
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.
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Observations
Based on a review of client records, the facility failed to keep the specific information to be released on consent to release information forms within the limits established by 4 Pa. Code 255.5 (b) in seven of seven applicable client records reviewed.
Client # 1 was admitted to residential level of care on May 10, 2021 and discharged on August 3, 2021. A release of information form to a funding source was signed and dated by the client on May 11, 2021 and allowed for the release of intake assessments, drug and/or alcohol use history and treatment records, trauma and/or abuse history, mental health history and/or psychiatric evaluations and progress notes, medical history and physical evaluations, progress notes, and/or consults, medication list, lab and/or test results, HIV/AIDs related health information, and ASAM forms-all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 2 was admitted to residential level of care on May 21, 2021 and discharged on July 27, 2021. A release of information form to a funding source was signed and dated by the client on May 24, 2021 and allowed for the release of intake assessments, drug and/or alcohol use history and treatment records, trauma and/or abuse history, mental health history and/or psychiatric evaluations and progress notes, medical history and physical evaluations, progress notes, and/or consults, medication list, lab and/or test results, HIV/AIDs related health information, and ASAM forms-all of which exceeded the limits established by 4 Pa. Code 255.5. Additionally, a release of information form to an outside individual was signed and dated by the client on May 24, 2021 and that consent form did not document the specific information to be disclosed.
Client # 3 was admitted to residential level of care on May 19, 2021 and discharged on July 7, 2021. A release of information form to a funding source was signed and dated by the client on May 21, 2021 and allowed for the release of intake assessments, drug and/or alcohol use history and treatment records, trauma and/or abuse history, mental health history and/or psychiatric evaluations and progress notes, medical history and physical evaluations, progress notes, and/or consults, medication list, lab and/or test results, HIV/AIDs related health information, and ASAM forms-all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 4 was admitted to residential level of care on April 30, 2021 and discharged on June 3, 2021. A release of information form to a funding source was signed and dated by the client on May 3, 2021 and allowed for the release of intake assessments, drug and/or alcohol use history and treatment records, trauma and/or abuse history, mental health history and/or psychiatric evaluations and progress notes, medical history and physical evaluations, progress notes, and/or consults, medication list, lab and/or test results, HIV/AIDs related health information, and ASAM forms-all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 5 was admitted to residential level of care on June 30, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on June 22, 2021 and allowed for the release of intake assessments, drug and/or alcohol use history and treatment records, trauma and/or abuse history, mental health history and/or psychiatric evaluations and progress notes, medical history and physical evaluations, progress notes, and/or consults, medication list, lab and/or test results, HIV/AIDs related health information, and ASAM forms-all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 6 was admitted to residential level of care on June 24, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on June 25, 2021 and allowed for the release of intake assessments, drug and/or alcohol use history and treatment records, trauma and/or abuse history, mental health history and/or psychiatric evaluations and progress notes, medical history and physical evaluations, progress notes, and/or consults, medication list, lab and/or test results, HIV/AIDs related health information, and ASAM forms-all of which exceeded the limits established by 4 Pa. Code 255.5.
Client # 7 was admitted to residential level of care on August 8, 2021 and was still active at the time of inspection. A release of information form to a funding source was signed and dated by the client on August 10, 2021 and allowed for the release of intake assessments, drug and/or alcohol use history and treatment records, trauma and/or abuse history, mental health history and/or psychiatric evaluations and progress notes, medical history and physical evaluations, progress notes, and/or consults, medication list, lab and/or test results, HIV/AIDs related health information, and ASAM forms-all of which exceeded the limits established by 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director and Assessment Director will ensure that all releases of information will not exceed the limits established by 4 PA Code 255.5(b).
If the clients are still in the program the Clinical Director will ensure that their release of information will be corrected and will not exceed the limits established by 4 PA Code 255.5(b).
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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 document the purpose of disclosure on consent to release information forms in one of seven applicable client records reviewed.
Client # 2 was admitted on May 21, 2021 and discharged on July 27, 2021. A release of information form to an outside individual was signed and dated by the client on May 24, 2021 and the form did not document the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Assessment Director as well as the Clinical Director will ensure that all consents to release information must document the purpose of the disclosure.
If client is still in treatment the Clinical Director will ensure that the release of information has a purpose documented. |
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 assure that a copy of a client consent was offered to the client in one of seven applicable client records reviewed.
Client # 3 was admitted on May 19, 2021 and discharged on July 7, 2021. A release of information form to a recovery project was signed and dated by the client on June 3, 2021 and the form did not document that a copy of the form was offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Assessment Director will ensure that all clients will be offered a copy of the consent form for releases of information. The Assessment unit will be made aware that the clients need to be offered a copy of the consent. |