INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 28, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Lehigh County Center for Recovery 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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705.4 (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, it was observed that the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside of the counseling room as cameras were operating in the group counseling room in the dining room.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director submitted on 4/13/23 the DDAP an exemption that cameras will be allowed in the dining room area for safety reasons. All group counseling session have been moved, as of 4/13/23, to the large group room in the front of the building and cameras will be turned off during that time of counseling sessions. In the large group room. Facility Manager will review daily to ensure compliance. |
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 the client records, the facility failed to document that a copy of a client consent shall be offered to the client and a copy maintained in the client record in one out of nine client records reviewed.
Client #4 was admitted on March 17, 2023 and was still active at the time of the inspection. A release of information form for a facility on March 22, 2023 did not have documentation that the client was offered a copy of the consent form.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Program Director reviewed, on 3/31/23, that all blank copies of the release of information utilized have the complete information on the copies. All incomplete blank forms were destroyed and replaced with complete forms. In addition, all staff with retrained in completing the release completely including that a copy was offered to the client, and they refused or accepted. Clinical Director will conduct weekly audits to ensure compliance. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on the review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project in two out of two applicable client record.
Client #8 was admitted on February 19, 2023 and discharged on February 22, 2023.
Client #9 was admitted on February 15, 2023 and discharged February 17, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Staff were trained on 4/18/2023 to complete a termination form to review with the client on how to appeal the decision of their administrative discharge. One copy is given to the client, and one is placed in their chart. Clinical Director will audit charts on a weekly basis to ensure compliance. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review of facility records, the facility failed to inform the Department of unusual incidents within the required three days. It was discovered that the facility had unusual incidents occur on May 2, 2022, May 5, 2022, May 13, 2022, June 30, 2022, July 16, 20222, August 11, 2022, September 6, 2022, October 13, 2022, November 28, 2022 December 3, 2022, January 16, 2023, January 17, 2023, January 22, 2023, and February 6, 2023 all of which involved presence of an ambulance. Upon further inspection, it was discovered that the facility had not submitted a written unusual incident report to the Department within the regulatory three business day timeframe.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed that all unusual incident reports are being submitted within the regulatory three business day timeframe with the staff who is assigned this task on 3/31/2023. Program Director will review on a monthly basis to ensure compliance. |