INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 20, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, New Way of Life 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 a review of personnel records and the facility staff schedule, the facility failed to provide at least one person in CPR certification and first aid training onsite during the hour of 7am to 8am on June 2, June 8, June 9, June 16, and June 23, 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with staff CPR certification all staff who require CPR certification or who's certification has expired were trained on CPR certification on August 4, 2022. To ensure continued compliance for CPR certification, the facility director in conjunction with the corporate training director will review staff CPR certification on a monthly basis to ensure continued compliance with staff scheduling ratios to ensure that a staff member trained in CPR certification will be on each scheduled shift seven days a week. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on a physical plant inspection, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. A camera was located in the corner of a room used for group therapy sessions.
The findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the September 8, 2021 annual licensing inspection.
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Plan of Correction
To ensure compliance with client privacy so that no counseling or group sessions can be seen or heard. On August 8, 2022 the camera that was in the group room area was removed from the room so that no group sessions could be seen or heard. To ensure continued compliance no cameras will be added anywhere in the building that would be used for counseling or group sessions. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to develop a policy and procedure for contacting an emergency contact after the client leaves a residential facility against medical advice.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with treatment/rehabilitation management, the policy and procedure committee met on July 22, 2022 to correct the policy regarding contacting the emergency contact of any individual leaving the program against medical advice. The policy was corrected on July 22, 2022 to include the contacting of the emergency contact in the event an individual leaves the program against medical advice. |
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 two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in client records # 5 and 7.
Client # 5 was admitted on February 22, 2022 and was discharged on May 31, 2022. A letter dated May 31, 2022 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information.
Client # 7 was admitted on April 15, 2022 and was discharged on May 26, 2022. A letter dated May 26, 2022 to "To whom it may concern" was documented in the client record without a valid informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure compliance with confidentiality, the staff will be trained on informed and voluntary consent from the client for disclosure of information on August 3, 2022. The staff will be specifically trained in the area of any letter that would need to be distributed for a specific client will include the proper name and address of the individual to receive the letter regarding the update of treatment status or successful completion of program. To ensure compliance the Clinical Supervisor will check any letters in client file, that they are addressed to a proper name and address during weekly chart audits. |