INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 6-7, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Snug Harbor Rehabilitation and Recovery, LLC 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to document that the facility director met the qualifications for the position in one of one record.Staff #1 was hired in a non-clinical position on June 8, 2020 and promoted to the facility director position on April 18, 2022. Staff #1 meets the experiential requirements for the position; however, the degree that staff #1 holds does not meet the educational requirement. Staff #1 provided documentation of an Associate of Arts degree, but there was no major associated with the degree.These findings were reviewed with facility staff during the licensing process.This is a repeat citation from the March 23, 2023 licensing renewal inspection.
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Plan of Correction
Individual has enrolled for the 6 credits needed to complete BA in Psychology.
During the time they are completing this task, another trained and experienced employee will temporarily oversee programming responsibilities. This individual meets all DDAP requirements.
All present and future staff will meet state required qualifications for Program Manager and all other positions
Executive Director will oversee this transition which will begin 2/1/24.
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the facilities training documents, the facility failed to document an annual evaluation of the overall training plan for the 2022 through 2023 complete training year.Additionally, the facility failed to have a current policy and procedure on the completion of an annual evaluation of the overall training plan. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A new form has been developed which will be used every September when we hold our staff meeting to review and plan our training year. This form will clearly document those in attendance and new ideas for trainings and those topics we will continue to offer.
This form has been developed. Facility Manager /Executive Director will ensure this process is completed correctly.
It will be available 2/1/24 |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to document that staff completed TB/STD and HIV/AIDS training using a Department approved curriculum in one of one personnel records. Staff #1 was hired as a support staff on June 8, 2020 and promoted to facility director on April 18, 2022. Approved TB/STD and HIV/AIDS training was due to be completed by June 8, 2022. Staff #1 did not complete the required four hours of TB/STD training utilizing Department approved curriculum. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from the March 23, 2023 licensing renewal inspection.
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Plan of Correction
All employees will be reeducated on the importance of the HIV/TB/AIDS/STD DDAP approved trainings within 1 year of employment for counselors and support personnel will complete within 2 years of employment.
This was discussed with all personnel.
Staff needing this training will register for the next available session. By 2/1/24
Executive Director will monitor this process which will be completed before our training year ends on September 30th. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a review of the facilities physical plant, the facility failed to ensure cold foods were kept at or below 40 degrees Fahrenheit and frozen foods were kept at or below 0 degrees Fahrenheit. The refrigerator located in Cottage 1 thermometer read 43 degrees Fahrenheit and the second refrigerator located in Cottage 1 thermometer read 45 degrees Fahrenheit. The freezer located in Cottage 1 thermometer read 6 degrees Fahrenheit. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff has been reeducated on recording temperatures in fridge. They understand the temps should be no greater than 40 degrees and not recorded after door has been held open. They have been instructed not to change the temperature inside the refrigerator but to maintain 40 degrees.
Both freezer and refrigerator temps are currently within required safety limits.
Staff has been trained not to change the interior temperature settings.
Lead House Monitor will be responsible for ensuring this is correct. This will be effective immediately and by 2/1/24. Property Manager will make random checks to ensure temperatures are correct. |
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 review of the physical plant, the facility failed to ensure that all fire extinguishers are inspected and approved annually by the local fire department of fire extinguisher company. The fire extinguisher in the charting room in Cottage 1 was last serviced June 2021 and due to be inspected by June 2022 and again June 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Property Manager and Security have been informed to double check after on site inspection by our Fire Monitoring Company to be certain they have not missed tagging all fire extinguishers to current status.
Chart room is locked, however Property Manager has been instructed to unlock door to ensure fire extinguisher is tagged with current dates after fire monitoring service makes checks.
Property Manager will make certain all extinguishers are tagged and dated properly and will make weekly checks to ensure tags are current.
Property Manager will be responsible and it is currently in place with final date 2/1/24. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of the facilities fire drill logs, the facility failed to set off a fire alarm or smoke detector during each fire drill.Reviewed fire drill logs from April 2023 through November 2023. There was no documentation of a fire alarm or smoke detector being set of with any fire drill from April 2023 through November 2023. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Property Manager and Security conduct regular fire drills. During drills the alarm is set off after and taken off after the drill the fire alarm is placed back on line for monitoring .
They have been reeducated on the importance of documenting system off line for drills and document back on line as drills are completed.
Property Manager is responsible for ensuring this is documented correctly.
It is currently in place
2/1/24 aa final date for implementation. |
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 obtain an informed and voluntary consent to release information which includes the specific information to be disclosed in one of seven records.Client #3 admitted to residential on October 28, 2023 and still a current client. An informed and voluntary consent dated November 23, 2023 to a personal support did not provide the specific information to be disclosed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff has been re-educated on the need to adhere to policies for specific information they are permitted to release with a signed ROI.
The Clinical Supervisor will be responsible for ensuring this documentation is correct and that staff follows policy.
Random charts are audited weekly as well as all charts reviewed upon discharge and as needed. This will ensure our specific information to be shared is correct.
This has been corrected and will be reviewed by 2/1/24. |
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 obtain an informed and voluntary consent to release information which included the purpose for disclosure in one of seven records.Client #2 admitted residential on October 21, 2023 and still a current client. A release of information was signed to an agency on November 23, 2023 which did not indicate the purpose of disclosure.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff has been re-educated on the need to record the purpose of an ROI in addition to adhering to company policy regarding the specific information permitted to release. This took place on 12/8/23
The ROI must have a purpose and Clinical Supervisor will ensure this is captured in the documentation. Staff has been reeducated to capture the purpose of the ROI and document correctly.
Clinical supervisor will be responsible for ensuring this documentation is complete and correct and that policies are followed through regular chart audits.
This will be reviewed again by 2/1/24 |