INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 9, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, DARS, Inc. Supervised Independent Living Program was found to not 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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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection, the facility failed to maintain furnishings in a state of good repair in the client lounge located on the fourth floor. A couch in the lounge had a tear and was in disrepair.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The couch in the fourth floor client lounge was discarded and replaced.
During weekly facility checks, the Maintenance Supervisor will inspect for any damaged furniture in all client areas.
Damaged items will be removed from use and repaired or replaced as needed. |
705.7 (b) (3) 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:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to store utensils in a clean enclosed area. Cooking utensils were on the counter in an open container.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Utensils are now located in a sealed container with a closing lid. This will be maintained by the kitchen supervisor and checked daily. |
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 two of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to keep the specific information disclosed within the limits of 255.5.
Client # 2 was admitted on May 26, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a probation officer dated May 26, 2021 allowed for the release of the discharge summary, aftercare plan, and service plan. Also, an informed and voluntary consent from the client for the disclosure of information to an employer dated May 26, 2021 did not provide the specific information to be released.
Client # 4 was admitted on May 5, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to a probation officer dated May 6, 2021 allowed for the release of the discharge summary, aftercare plan, and service plan. A correspondence with probation that occurred on July 7, 2021 and September 7, 2021 provided detailed information on client treatment to include: background information, previous treatment experience, treatment progress, treatment goals, groups completed, family participation, education, psychiatric care, and community service hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The DARS SIL program treats clients who are adjudicated through the courts, recommended for treatment by juvenile probation, and are voluntarily participating in treatment with no legal involvement.
Upon clarification by the licensing specialist, it is understood that discharge summaries may only be released to probation in cases where the client is court-committed to treatment. SOP 709.24 (a) (3) has been updated to reflect this change and the Clinical Director will ensure compliance.
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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 one 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 to include the purpose of the disclosure.
Client # 6 was admitted on November 11, 2020 and was discharged on June 11, 2021. An informed and voluntary consent from the client for the disclosure of information to the SCA dated November 11, 2020 did not provide the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Clinical staff will receive a refresher training on the requirements of completing voluntary consent forms. This training will be conducted internally and will cover all aspects of the consent forms.
Training will be provided by the Director of Program Development and the Clinical Director will ensure compliance through monthly file inspections. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on two of five client records reviewed, the facility failed to provide a complete client record to include a physical examination in client records # 1 and # 3.
Client # 1 was admitted on August 16, 2021 and was still active at the time of the inspection. There was no physical examination in the client record.
Client # 3 was admitted on May 28, 2021 and was still active at the time of the inspection. There was no physical examination in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The documentation of physical examinations missing in these files remained in the Manos House clinical records despite these clients transitioning from Manos House to Supervised Independent Living.
It is the policy of DARS, that copies of all required documentation will be transferred into the new client record once a client transitions from Manos House to SIL.
Clinical staff in both programs will receive an internal refresher training on this issue and ongoing compliance will be monitored by the Clinical Director via a file inspection at the conclusion of the client's first week in the SIL program. |
709.53(a)(5) LICENSURE Progress Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on three of seven client records reviewed, the facility failed to provide progress notes of counseling sessions documented on the record of service in client records # 1, 2, and 3.
Client # 1 was admitted on August 16, 2021 and was still active at the time of the inspection. A review of the record of service indicated individual sessions occurred on August 24, 25, and 30, 2021. There were no progress notes for these sessions in the client record.
Client # 2 was admitted on May 26, 2021 and was still active at the time of the inspection. A review of the record of service indicated individual sessions occurred on August 10, 2021 but there was only one progress note indicating a family session. Also, the record of service indicated an individual session on August 2, 2021 but there was not a progress note for this session in the client record.
Client # 3 was admitted on May 28, 2021 and was still active at the time of the inspection. A review of the record of service indicated an individual session occurred on August 20, 2021. There was no progress note for this session in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The individual progress notes for these clients were located in the primary counselor's office, but had not been filed in the client record. Upon notification of this deficiency, these notes were added to the client records.
The counselor has been reminded of the requirement for all progress notes to be present in the client record at all times.
The Clinical Director will ensure this does not recur by reviewing this counselor's files on a weekly basis for the next 3 months to verify progress notes have been filed. Following this 3 month period, if no further issues are noted, the Clinical Director will resume monthly file inspections. |