INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Diocese of Harrisburg, PA, 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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704.11(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
Based on the review of CPR records and staffing schedules, the facility failed to ensure that at least one CPR trained person was on site from 12:00am through 8:00am from the dates of June 17, 2023 through June 30, 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director already reached out to the American Red Cross to schedule training in CPR for all staff who are not trained, which includes all the overnight staff whose certifications have ended. All staff who have expired certificates will be re-trained before the end of the calendar year.
The Program Director will create a spreadsheet to monitor all staff CPR certifications to prevent future lapses in certifications. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records and a discussion with facility staff, the facility failed to document that all staff were Instructed in the use of the fire extinguishers upon staff employmentEmployee #2 was hired as the facility director on May 30, 2023 and was still in that role at the time of the inspection. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
All employees will be instructed on how to use the fire extinguishers and the location of all fire extinguishers at the November 2023 staff meeting.
Each November during staff meeting, all staff will have a refresher on how to use the extinguishers.
The employee orientation and hiring checklist will ensure that all new staff are instructed on how to use the fire extinguishers and their locations in the building. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records and a discussion with facility staff, the facility failed to document that all staff were trained to perform assigned tasks during emergenciesEmployee #2 was hired as the facility director on May 30, 2023 and was still in that role at the time of the inspection. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
At the November staff meeting, all staff will participate in a refresher training on expected tasks during an emergency,
Every November staff meeting, there will be a refresher training on the tasks to complete during an emergency.
The new orientation checklist will include training on emergency tasks. |
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 the facility's policy and procedure manual and a discussion with facility staff, the facility failed to prepare, annually update and sign a written manual delineating project policies and procedures.The findings were discussed with facility staff during the licensing process.
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Plan of Correction
By the end of the calendar year, the policies and procedures will be reviewed by the Program Director, updated as appropriate.
All staff will be provided the updated policies and procedures at the January staff meeting for review.
In the future, each Spring policies will be reviewed and updated as appropriate by the Program Director and HR Director. |
709.26 (a) (1) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(1) Utilization of volunteers.
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Observations
Based on a review of the facility's policy and procedure manual the facility failed to adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws that addresses the utilization of volunteers. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
The use of volunteer's policies does exist. It was an oversight on the part of the facility to not have provided them during the audit. An electronic folder will be created where all policies are maintained for the program. The Program Director will be responsible for ensuring the folder is created with the proper policies and procedures.
The policies will be found by the Program Director and included in the policy manual for future updates and awareness for staff. |
709.26 (a) (2) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(2) Rules of conduct.
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Observations
Based on a review of the facility's policy and procedure manual the facility failed to adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws that addresses the rules of conduct. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility does have a policy on rules of conduct and ethics for staff. It was not provided during the audit.
The policy will be located by the Program Director and included in the policy manual.
All staff will be provided the updated policies and procedures at the January staff meeting for review.
In the future, each Spring policies will be reviewed and updated as appropriate by the Program Director and the HR Director. |
709.26 (a) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(3) Supervision of staff.
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Observations
Based on a review of the facility's policy and procedure manual the facility failed to adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws that addresses the supervision of staff. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility does have a policy on rules of supervision for staff. It was not provided during the audit.
The policy will be located by the Program Director and included in the policy manual and on the electronic folder.
All staff will be provided the updated policies and procedures at the January staff meeting for review.
In the future, each Spring policies will be reviewed and updated as appropriate by the Program Director and the HR Director. |
709.26 (a) (4) LICENSURE Personnel management.
§ 709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws. In addition, the written policies and procedures must specifically include, but are not limited to:
(4) Orientation of new employees.
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Observations
Based on a review of the facility's policy and procedure manual the facility failed to adopt and have implemented written project personnel policies and procedures in compliance with State and Federal employment laws that addresses the orientation of new employees. The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility does have a new hire check list that addresses the education of new employees on policies and procedures. Checklist needs to be signed by staff and supervisor upon completion of the checklist. It was not provided during the audit.
All future hires will be on-boarded using the approved checklist for appropriate orientation by the Program Director. The signed checklist will be kept in their personnel file.
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709.31 (b) LICENSURE Data collection system
§ 709.31. Data collection system.
(b) The recordkeeping system must allow for the identification of clients' admissions and discharges within a specific time period.
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Observations
Based on a discussion with facility staff, the facility failed to maintain a recordkeeping system that allows for the identification of clients' admissions and discharges within a specific time period. At the time of the inspection, the facility's recordkeeping system had not been updated since November 2022. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
An admissions and discharge spreadsheet will be created by the Program Director to track all resident's date of admission and discharge.
This spreadsheet will be created by the Program Director and implemented by the end of November.
Completion of the admission spreadsheet will be done by the Drug and Alcohol counselor for their respective clients. |
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
Based on a review of ten client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in eight client records reviewed. Client#1 was admitted on May 23, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on June 15, 2023 indicates an individual session and group session to occur one time a week. A review of progress notes and record of service only showed two individual sessions happening on May 23, 2023 and August 3, 2023 and no group session since June 13, 2023. Client #2 was admitted on June 15, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on June 15, 2023 indicates an individual session and group session to occur one time a week. A review of progress notes and record of service only showed two group sessions since admission occurring on June 20, 2023 and August 1, 2023. Client #3 was admitted on June 29, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on June 29, 2023, indicates an individual session and group session to occur one time a week. A review of progress notes and record of service showed missing individual and group session for the weeks of July 30-August 5, 2023 and August 6- August 12, 2023.Client #4 was admitted on March 28, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on April 12,, 2023 indicates an individual session and group session to occur one time a week. A review of progress notes and record of service only showed that no individual session documented since July 6, 2023 and no group session documented since August 25, 2023. Client #5 was admitted on April 12, 2023, and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on April 12, 2023, indicates an individual session and group session to occur one time a week. A review of progress notes and record of service only showed no individual sessions documented since May 18, 2023. Client #6 was admitted on July 18, 2023 and was still active at the time of the inspection. A comprehensive treatment and rehabilitation plan developed on July 18, 2023 indicates an individual session and group session to occur one time a week. A review of progress notes and record of service only showed only one group note and no individual session documented. Client #7 was admitted on April 27, 2023 and was discharged on June 20, 2023.A comprehensive treatment and rehabilitation plan developed on May 12, 2023 indicates an individual session and group session to occur one time a week. A review of progress notes and record of service missing group session from May 9 through May 24, 2023 and from May 24 through June 5, 2023. Client #8 was admitted on April 13, 2023 and discharged on July 3, 2023. A comprehensive treatment and rehabilitation plan developed on May 5, 2023 indicates an individual session and group session to occur one time a week. A review of progress notes and record of service missing group session from May 10 through May 24, 2023 and from May 30 through June 13, 2023. Client #9 was admitted on December 14, 2022 and was discharged on May 23, 2023Client #10 was admitted on December 12, 2022 and was discharged on December 29, 2022. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff that were responsible for providing services and maintaining records are no longer with the facility.
To ensure charts are maintained properly moving forward, treatment plans will be updated within 24 hours of the 30-day mark by counselors. The program director will check charts randomly each month to ensure charts are compliant with treatment plans, case notes and other documentation. There will be two Resident Attendants (RA) who will review charts each shift they work and notify the counselor when a chart needs updated or documentation is missing. Counselors will be trained on the policy related to treatment plan updates and proper charting for residents. |