INITIAL COMMENTS
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This report is a result of an on-site part two inspection conducted on February 8, 2021 by staff from the Bureau of Program Licensure. Based on the findings of the on-site complaint investigation, Self Help Movement was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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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 an administrative review, the facility failed to demonstrate sufficient coverage of staff certified in CPR or First Aid on the following dates and shifts:
June 5, 2020 - 11:00 P.M. to 7:00 A.M.
June 8, 2020 - 3:00 P.M. to 11:00 P.M.
June 12, 2020 - 11:00 P.M. to 7:00 A.M.
June 15, 2020 - 3:00 P.M. to 11:00 P.M
June 19, 2020 - 11:00 P.M. to 7:00 A.M.
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
Due to Covid-19, Self Help Move-
ment was unable to have employees
re-certified for First Aid/CPR
Training when their certifications had expired. All employees that were scheduled to be re-certified as of April, 2020 were re-certified by the end of June, 2020.
The Compliance Department will make an updated list, and set-up training to ensure that all shifts have updated CPR/First Aid training/re-certification on a timely basis.
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705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on the physical plant inspection conducted on February 08, 2021, the facility failed to ensure the building was safe and in good repair.
A light bulb in room 318, was observed to have been painted red which creates a fire hazard.
The following rooms have mounted light fixtures with missing pull chain causing the light bulbs to be manually twisted into/out of the fixtures for use. rooms 363, 371, 373, 317, 355, 313, 352, 346, 338, 308, 316, 318 320, 330, 329, 321, 319, 313, 331.
The light fixture in the following rooms failed to have light bulbs: rooms 2A, 111, 107, 103, 2C, 79, 75, 66.
The closets located in the following bedrooms failed to have doorknobs; rooms 368, 304, 322, 324, 328, 327, 325, 321, 319, 311, 331.
The following bedrooms had numerous missing and/or broken window shades in rooms; 376, 374, 345, 106, 375, 370, 335, 339, 318, 97, 66.
The following bedrooms had wall damage and large amount of peeling paint in rooms 372, 309, 313, 316, 320, 332, 2B and 368, 313, 316.
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Plan of Correction
The Director of Building & Maintenance will ensure that the building is safe and in good repair by having the supervisors on the floor document on a maintenance checklist the things that need to be repaired or fixed. He will then have the Maintenance Department repair or fix the items.
The light bulb in 318 has been replaced with a standard light bulb by the Maintenance Department. This has been supervised by the Director of Building & Maintenance.
The Maintenance Department has replaced the light fixtures with chains to light switches with knobs that turn. This was supervised by the Director of Building & Maintenance.
The Maintenance Department has replaced the light bulbs in all the rooms. This was supervised by the Director of Building & Maintenance.
The closet doors do not need knobs because they have no closing mechanisms. The are pulled open and shut by hand.
The Maintenance Department has replaced all window shades in the rooms. This was supervised by the Director of Building & Maintenance.
The residents are responsible for letting the Maintenance Department know when their rooms need to be fixed or painted by putting request slips in the Maintenance Department Request Book.
All rooms have been re-painted and damaged walls have been fixed.
The Director of Building & Maintenance will ensure that all rooms are painted and damaged walls are fixed on a monthly basis.
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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 the physical plant inspection conducted on February 08, 2021, the facility failed to maintain furnishings in a state of good repair
Furniture located in the second and third floor lounges were observed to be ripped and in need of cleaning.
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Plan of Correction
The Director of Building & Maintenance will ensure that the building is safe and in good repair by having the supervisor(s) on the floor(s) document on a Maintenance Department Checklist the items that need to be repaired or fixed. He will then have the Maintenance Department repair or fix the item.
The furniture in the lounges have been replaced by the Maintenance Department. This was supervised by the Director of Building & Maintenance.
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on the physical plant inspection conducted on February 09, 2021, the facility failed to ensure that all showers had slip resistant surfaces.
showers located on the second and third floor
bathroom located in room 300B.
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Plan of Correction
Three (3) days before the inspection the strips for the slip- resistant floor were replaced. Signs were placed in the bathroom along with caution tape indicating to wait until the strips dried before taking a shower. The clients took down the signs and caution tape and proceeded to use the showers before the strips dried. This caused the strips to come up.
The Director of Building & Maintenance will ensure that the strips are replaced and glued down with a better adhesive, and that the clients will be instructed to wait until the adhesive has dried.
The Director of Building & Maintenance will ensure that a monthly check is done to ensure that the strips are still in place and in good condition.
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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 the physical plant inspection conducted on February 08, 2021, the facility failed to display proper temperature readings within refrigerators, additionally a freezer located in the basement, next to the chapel, failed to also include temperature reading.
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Plan of Correction
The Director of Food Services has placed thermometers and logs on all refrigerators and freezers and will ensure that this is done on a continuous basis. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on the physical plant inspection conducted on February 08, 2021, the facility failed to ensure it was free from insect infestation.
In a corner of room 378, heating room, what appeared to be a wasp nest was observed.
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Plan of Correction
Self Help Movement has a contract with Orkin Pest Control for insect infestation. The wasp nest that was observed was a nest that was old and had nothing in it. It has been removed. |
709.11-709.18 LICENSURE Subchapter B. Licensing Procedures
Subchapter B. Licensing Procedures
709.11. Application for license.
(a) Persons, partnerships, corporations, or other legal entities intending to provide drug and alcohol treatment services shall apply for a license from the Department. Application shall be made using forms and procedures prescribed by the Department.
(b) The license shall expire 1 year from the date of issuance. Prior to the expiration of the current license, the Department will notify the facility of the date for an annual on-site inspection for renewal of license.
(c) The Department will notify the appropriate SCA of applications for and issuance of a license to any facility or individual within the SCA's area of responsibility.
709.12. Full licensure.
(a) A license to operate the facility will be issued when, after an on-site inspection by an authorized representative of the Department, it has been determined that requirements for licensure under this chapter, have been met.
(b) A license will be issued to the owner of a facility and will indicate the name of the facility, the address, the date of issuance, and the types of activities the facility is authorized to provide.
(c) The current license shall be displayed in a public and conspicuous place in the facility.
709.13. Provisional licensure.
(a) The Department will issue a provisional license, valid for a specific time period of no more than 6 months when the Department finds that a facility:
(1) Has substantially, but not completely, complied with applicable requirements for licensure.
(2) Is complying with a course of correction approved by the Department.
(3) Has existing deficiencies that will not adversely alter the health, welfare or safety of the facility's clients.
(b) Within 15 working days of receipt of the deficiency report, facility staff shall submit a plan to correct deficiencies noted during the site visits.
(c) A provisional license may be renewed no more than three times.
(d) A regular license will be issued upon compliance with this part.
709.14. Restriction on license.
(a) A license applies to the person, the named facility, the premises designated therein and the activities noted, and is not transferable.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(1) Change in ownership.
(2) Change in name of the facility.
(3) Change in location of the facility.
(4) Change in activity/discontinuance of an activity.
(5) Change in authorized maximum capacity.
(6) Closing of facility.
(c) Failure to notify the Department under subsection (b) will result in automatic expiration of the license.
709.15. Right to enter and inspect.
(a) An authorized representative of the Department has the right to enter, visit, and inspect a facility licensed or applying for a license under this chapter.
(b) The authorized Department representative shall have full and free access to the records of the facility and its clients.
(c) The authorized Department representative has the right to interview clients as part of the visitation and inspection process.
709.16. Notification of deficiencies.
(a) The authorized Department representative will leave appropriate Department forms with the facility director to address areas of noncompliance with the standards.
(b) These forms shall be completed and submitted to the Division of Licensing within 15 working days after the site visit.
(c) A license may not be issued until a plan of action has been approved by the Department.
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(1) Failure to comply with a directive issued by the Department.
(2) Violation of, or noncompliance with, this chapter.
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
(4) Gross incompetence, negligence or misconduct in the operation of the facility.
(5) Fraud, deceit, misrepresentation or bribery in obtaining or attempting to obtain a license.
(6) Lending, borrowing or using the license of another facility.
(7) Knowingly aiding or abetting the improper granting of a license.
(8) Mistreating or abusing individuals cared for or treated by the facility.
(9) Continued noncompliance in disregard of this part.
(10) Operating a facility that, by nature of its physical condition, endangers the health and safety of the public.
(b) If the Department proposes to revoke or refuse to issue a license, it will give written notice to the facility by certified mail, stating the following:
(1) The reasons for the proposed action.
(2) The specific time period for the facility to correct deficiencies.
(c) If the facility does not correct the deficiencies within the specified time, the Department will officially notify the licensee that it shall show cause why its license should not be revoked under 1 Pa. Code Subsection 35.14 (relating to orders to show cause), and that it has a right to a hearing authorized by the Department on this question. A request to the Department for a hearing shall be filed, in writing, within 30 days of receipt of the show cause order.
(d) Subsection (c) supplements 1 Pa. Code Subsection 35.14.
709.18. Hearings.
(a) The Department will convene and conduct a show cause hearing for a facility under 1 Pa. Code Subsection 35.37 (relating to answers to orders to show cause) and this chapter.
(b) An administrative hearing held under this section shall be conducted under 1 Pa. Code Part II (relating to general rules of administrative practice and procedure).
(c) The Department may institute appropriate legal proceedings to enforce compliance with this chapter.
(d) This section supplements 1 Pa. Code Part II.
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Observations
Based on the physical plant inspection conducted on February 09, 2021, the facility failed to allow the Department full access to inspect the facility.
The facility failed to give licensing specialist access to the following areas:
Ground level and basement: therapeutic offices, administrative offices and client file chart rooms
Basement: unidentified storge room, cleaning supply room and dry food storage area.
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Plan of Correction
Due to clients in the facility having COVID the licensing team requested that our floors be cleared of clients when they did their tour (even the floors that did not have COVID cases), and because the team had started their inspection so late, they were informed that to do this we would have to wait until after lunch so that the clients could be placed safely throughout the building.
The team started the tour at approximately 12:45 p.m. At 6:00 p.m. the team was still on the tour and wanted to get into administrative offices, the chart room, storage areas, etc., but due to COVID, the clinical staff have staggered hours, and the administrative staff had already gone home for the day. It was not due to an unwillingness to comply, but that of time management.
All areas would have been accessible if the audit had been completed before the end of business hours.
The Director of Building and Maintenance and/or designee will ensure that the auditors can get into any area of the building at any time.
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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 the facility's inpatient non-hospital rehabilitation client records on February 8, 2021, the facility failed to document when the witnessed signed or when the client signed the release form. The form only had one spot for a date to cover both signatures.
Additionally, the facility failed to document an inform and voluntary consent in 3 client records.
12. Letter sent " To Whom It May Concern " , no date on the letter, but identifying information was documented on the letter.
13. A consent for probation and parole dated 11/16/2020 exceeds 4 PA Code 255.5 by allowing the release of discharge related information and aftercare plan.
14. A consent for probation and parole dated 9/17/2020 exceeds 4 PA Code 255.5 by allowing the client ' s aftercare plan and any behaviiral issues to be release.
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Plan of Correction
The Clinical Director as well as the Director of Intake will be responsible to ensure that the following is completed:
All consents are being revised to include date that witness signed as well as the client.
All charts will be more closely reviewed by Intake, the Clinical Director and assigned Counselor to ensure compliance.
This may have been a letter solely provided to the client to use at his discretion. These letters will be eliminated, and summary of care for MAT services will now be included in a different format, and only released to other providers with proper consent. Documentation of released information will be included in chart.
Legal consents are being revised to be in accordance with 4 PA Code 255.5.
The Clinical Director will go through the documented files and will have the Counselor correct the deficiencies that can be legally corrected due to the client no longer being at the facility.
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709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of the facility's inpatient non-hospital rehabilitation client records on February 8, 2021, the facility failed to include the following verbiage on the client rights form that the client signs.
A client receiving care or treatment under section 7 of the act (71 P. S. 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Plan of Correction
The Clinical Director will be responsible to ensure the following is completed:
Note: Current version of clients' rights includes verbiage of "I will not be deprived of my civil rights by reason of treatment, that I will not be discriminated against, that I have the right to inspect my personal records, that if denied access to my personal records, I have the right to appeal that denial to the program director, that I may request removal or correction of information contained in my personal records, and that I have the right to submit rebuttal of information contained in my personal record".
The Clinical Director will ensure that the Clients' rights for will be revised to make the specific verbiage listed under section 7 of the act (71 P.S. §1690.107).A client receiving care or treatment shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
The Clinical Director will go through the documented files and will have the Counselor correct the deficiencies that can be legally corrected due to the client no longer being at the facility.
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709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's inpatient non-hospital rehabilitation client records on February 8, 2021, the facility failed to include the following verbiage on the client rights form that the client signs.
The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Plan of Correction
The Clinical Director will be responsible to ensure that the following is completed:
Note: Current version of clients' rights includes verbiage of "I will not be deprived of my civil rights by reason of treatment, that I will not be discriminated against, that I have the right to inspect my personal records, that if denied access to my personal records, I have the right to appeal that denial to the program director, that I may request removal or correction of information contained in my personal records, and that I have the right to submit rebuttal of information contained in my personal record".
The Clinical Director will ensure that the Clients' rights will be revised to make the specific verbiage listed in
§709.30 regarding project not discriminating in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
The Clinical Director will go through the documented files and will have the Counselor correct the deficiencies that can be legally corrected due to the client no longer being at the facility.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of the facility's inpatient non-hospital rehabilitation client records on February 8, 2021, the facility failed to document and/or date when the follow-up was completed in three client records.
Client #15 was admitted on 8/13/2020 and discharged on 10/29/2020. The follow-up was not completed as of the date of the licensing inspection.
Client #16 was admitted on 6/14/2020 and discharged on 9/26/2020. The follow-up that was documented did not have a date when the follow-up was completed.
Client #17 was admitted on 3/3/2020 and discharged on 6/3/2020. The follow-up that was documented did not have a date when the follow-up was completed.
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Plan of Correction
The Clinical Director will be responsible to ensure that the following is completed:
That the follow-ups are completed within 7 days of discharge and
will revise form to ensure the date is recorded when follow-up is conducted.
The Clinical Director will go through the documented files and will have the Counselor follow up on clients not documented.
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709.72(a)(5) LICENSURE Activity Notes
709.72. 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) Activity notes.
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Observations
Based on a review of the facility's transitional living facility client records on February 8, 2021, the facility failed to document activity notes in all ten records reviewed.
Client #1 admitted on 5/9/2020.
Client #2 admitted on 6/21/2019. #3 admittted on 6/26/20
Client #4 admitted on 1/14/2021
Client #5 admitted on 7/19/2021
Client #6 admitted on 5/20/2020 and discharged on 12/14/2020
Client #7 admitted on 6/18/2020 and discharged on 10/9/2020
Client #8 admitted on 11/23/2020 and discharged on 12/9/2020
Client #9 admitted on 12/9/2019 and discharged on 8/2/2020
Client #10 admitted on 3/31/2020 and discharge on 11/4/2020
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Plan of Correction
The Supervisor of Transitional Living Facility will ensure that all activity notes are kept in the files instead of on the computer. The last inspector informed us we could keep the information on the computer. Since there was no exit interview, we were not asked for the notes. |