INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 22, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Peace and Harmony 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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705.28 (d) (6) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(6) Conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
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Observations
Based on a review of the facility's December 2023 through July 2024 fire drill logs, the facility failed to conduct fire drills on different days of the week, at different times of the day and on different staffing shifts.
At the time of the inspection, the facility's posted hours of operation were Monday through Thursday from 8:00AM to 8:00PM, and Friday from 8:00AM to 5:00 PM. Every fire drill conducted, during the reviewed period, was completed between 10:00AM and 4:40PM. There were no fire drills conducted during the facility's evening hours of operation.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Peace and Harmony House Compliance Officer will conduct an unannounced fire drill during the facility's evening hours of operation. He will make sure it is on all shifts moving forward. Peace and Harmony House Facility Director will examine the Fire Drill Log and make sure the Compliance Officer know the shifts he has completed and the shifts we still need a fire drill on monthly. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
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Observations
Based on an administrative review, the project failed to obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project's drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
At the time of the inspection, the Department representative was provided the project ' s financial statements, which were reviewed by a certified public accountant for the year ending December 31, 2023; however, there was no financial audit completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Peace and Harmony House has engaged the services of a certified public accounting firm, to conduct the annual financial audit. The audit will be scheduled to commence by 11/1/2024, ensuring that it is completed within the required time frame to meet all compliance obligations moving forward. Moving forward the audit for 2023 will be completed by 11/19/2024. CEO will make sure all financial records will be organized and made readily available to independent auditor for the audit. This includes financial statements, transaction records, and any other relevant documentation. |
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 a review of client records, the facility failed to complete an informed and voluntary consent to release information form prior to the disclosure of information in three of fourteen client records reviewed.
Client # 1 was admitted to the partial hospitalization activity on June 12, 2024 and was active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 10 was admitted to the outpatient activity on February 6, 2024 and was active at the time of the inspection. The release of information form to the funding source was signed by the client on May 9, 2023 and the form expired on May 9, 2024. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures made after May 9, 2024.
Client # 13 was admitted to the outpatient activity on January 24, 2024 and was discharged on May 13, 2024. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
This is a repeat citation from the October 3, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately Peace and Harmony House (Clinical Supervisor) created and compiled a new consent form from Peace and Harmony House to the funding source put in all intake packets moving forward. All admissions will fill out Peace and Harmony House funding source. New forms have been added already to charts. All active clients that are still at Peace and Harmony House has signed the funding source form. Clinical Supervisor will check all intakes within 24 hours to make sure that funding source consent is signed and in the chart. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client # 8 was admitted to the outpatient activity on June 18, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on June 25, 2024; however, the plan did not include the frequency of treatment and rehabilitation services to be provided to the client.
Client # 9 was admitted to the outpatient activity on January 31, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on March 22, 2024; however, the plan did not include the frequency of treatment and rehabilitation services to be provided to the client.
Client # 10 was admitted to the outpatient activity on February 6, 2024 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on May 24, 2024; however, the plan did not include the frequency of treatment and rehabilitation services to be provided to the client.
This is a repeat citation from the October 3, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately Clinical Supervisor(s) will complete a training within both offices on Treatment Plans in regard to intervention's frequency, how often, type, and time in clinical meeting and put in effect immediately on all new treatment plans created after audit / plan of correction provided date. All current client's treatment plans have been updated. Clinical Supervisor will audit all treatment plans within 24 hours of due date to make sure they have the frequency, how often, type, and time. |