INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on May 21-22, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, The Highland House, Inc. 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:
|
Plan of Correction
|
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
|
Observations
Based on a review of administrative information, the facility failed to document an assessment of staff training needs for the July 2024 to June 2025 training year.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
All staff will be provided with an annual assessment of trainings that is individualized and signed off by the staff member and the Acting Executive Director.
The agency will be in full compliance by July 31st, and this will be completed by the Acting Executive Director. Once the merger is completed, this responsibility will become the SCA's HR Specialist's.
An Outlook reminder will be placed on the Acting Executive Director's calendar as a reminder to complete this annually by June 15th. |
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.
|
Observations
Based on a review of administrative information, the facility failed to document an annual evaluation of the overall training plan for the July 2023 to June 2024 training year.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Acting Executive Director will complete the annual evaluation for FY 23-24 and for FY 24-25 by July 31, 2025.
The Acting Executive Director will document in Outlook as a reminder to complete this annually for all future years. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records, the facility failed to develop a written individual training plan for each employee in four of four records for the July 2024 to June 2025 training year.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Acting Executive Director will ensure that individual training plans are completed as required in the policy for the new fiscal year. All individual plans will be completed with the employee by July 31, 2025.
A reminder will be placed in Outlook to complete all individual training plans for May 1st of each year. |
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure a counselor received the minimum of at least6 hours of HIV/AIDS and 4 hours of TB/STD and other health related topics within the first year of employment in one of one record.
Staff #3 was hired as counselor on May 6, 2024 and still employed at time of inspection. Staff #3 was due to have the communicable disease trainings no later than May 6, 2025. There was no documentation provided of the completion of the HIV/AIDS or TB/STD training as of the date of the inspection.
The findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
This employee did have the TB/STD/Hepatitis training on October 30, 2018. The employee was having some difficulties getting a copy of the certificate to management.
This employee was also attended the HIV/AIDS training on May 23, 2025. Both certificates can be provided if necessary.
The Executive Director will ensure to monitor training requirements closely for new staff to ensure all staff receive the required training. Reminders will be put into Outlook to review quarterly for compliance. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of the staffing records, the facility failed to ensure all personnel were instructed in the use of fire extinguishers upon employment in one of four records reviewed.
Staff #4 was hired as a support staff on November 25, 2024 and still a current employee. The fire extinguisher training was not completed at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 15, 2024 licensing renewal inspection.
|
Plan of Correction
This employee has been trained again and the form has been signed. An onboarding checklist has been created so this does not occur again.
Moving forward, the Acting Executive Director will ensure all staff are trained during the onboarding process and that documentation is housed in the personnel file. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of the staffing records, the facility failed to ensure all personnel were trained to perform assigned tasks during emergencies in one of four records reviewed.
Staff #4 was hired as a support staff on November 25, 2024 and still a current employee. Verification the staff was trained to perform assigned tasks during emergencies was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the May 15, 2024 licensing renewal inspection.
|
Plan of Correction
This staff member was indeed trained upon hire, but the documentation was not completed. The employee will be retrained by July 31, 2025. An onboarding check list has been created so this does not occur again.
The Acting Executive Director will be responsible for ensuring staff are trained and documentation is housed in the personnel file. |
709.25 LICENSURE Fiscal Management
§ 709.25. Fiscal management.
The project shall obtain the services of an independent certified public accountant for an annual financial audit of activities associated with the project ' s drug/alcohol abuse services, in accordance with generally accepted accounting principles which include reference to the drug and alcohol treatment activities.
|
Observations
Based on a review of administrative documents and an interview with the director, the project failed to document an annual financial audit for the fiscal year ending June 30, 2023.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The previous Director was responsible for this fiscal year. The Acting Director has been contracted since November 20, 2023, to manage the facility. The documents the auditors are requesting have not been able to be found and the auditors have not provided a resolution for this. Therefore, it has been difficult to complete the audit. The agency will be filing a request for an exception on submission of this audit. If the exception is not approved, the audit will be completed as soon as the auditor's schedule will permit and they will be contacted by July 10, 2025 to start working in this direction. The Acting Executive Director will ensure all audits are completed timely moving forward. The Acting Executive Director will contact the auditors to schedule the FY 23-24 and the FY 24-25 audit by July 25th, 2025. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
|
Observations
Based on a review of personnel records, the facility failed to document annual written individual staff performance evaluations in two of two applicable records.
According to the facilities policy and procedure, annual performance evaluations are to be completed with supervisor and employee annually by hire date.
Staff #2 was hired as a clinical supervisor on December 4, 2023 and still employed. The annual performance evaluation was not completed at the time of the inspection.
Staff #3 was hired as a counselor on May 6, 2024 and still employed. The annual performance evaluation was not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The Executive Director will send reminders in Outlook to ensure that all staff evaluations are completed timely. The outlook reminders will be set 30 days prior to the due date to allow for adequate time to complete. A second outlook reminder will be set for seven days prior to the due date.
The outstanding staff evaluations will be completed by July 31, 2025, for the Counselor and Clinical Supervisor. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
Based on a review of administrative information, the facility failed to provide documentation of inspection of storage areas that ensures compliance with state and federals and program policy.
The facility ' s policy and procedure states the inspection of storage areas should be done quarterly. No inspection logs were provided during inspection.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Management has been inspecting storage areas and will ensure the inspections are logged in writing quarterly beginning with the June 30,2025 quarter.
The Clinical Director will ensure that the quarterly inspections are completed within 10 days of the end of the quarter. An outlook reminder will be placed in her calendar two weeks prior to the end of the quarter as a reminder. The Executive Director will schedule an outlook reminder one week prior to the end of the quarter to follow up with the Clinical Director to ensure the inspections have been completed.
The documentation for the 2nd quarter of 2025 will be completed by July 31, 2025. |
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.
|
Observations
Based on a 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 of four applicable client records.
There was no documentation of the facility notifying two clients of the decision to terminate treatment in the client record.
Client #1 was admitted on December 19, 2024, and administratively discharged on May 19, 2025.
Client #9 was admitted on October 15, 2024, and administratively discharged on November 19, 2024.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
This was discussed and these clients refused to complete the discharge paperwork. Any future discharges who refuse to complete the paperwork, will include documentation in the agency's EHR and a letter will be provided to the client even if refused.
In the future, the Clinical Director will ensure this is completed upon occurrence. The Assistant Administrator will follow up with the Clinical Director within 24 hours of discharge to ensure a letter has been mailed to the client. This procedure will be in place by July 31, 2025. |
709.51(a)(4) LICENSURE Involuntary discharge/termination criteria
709.51. Intake and admission.
(a) The project director shall develop a written plan providing for intake and admission which includes, but is not limited to:
(4) Involuntary discharge/termination criteria.
|
Observations
Based on a review of client records, the facility failed to notify the emergency contact of a client's decision to leave against facility advice in two of two applicable records.
The facility's policy and procedure states the client ' s emergency contact will be notified within 12 hours of the client ' s decision to leave against facility advice.
There was a consent for the emergency contact in both client records but no documented attempt to contact emergency contact following discharge.
Client #2 was admitted on January 21, 2025, and discharged on April 30, 2025.
Client #8 was admitted on May 1, 2025, and discharged on May 12, 2025.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
When a client leaves against facility advise, the Clinical Director will ensure that the emergency contact is notified and that documentation is noted in the electronic health record.
The Assistant Administrator will follow up with the Clinical Director on the day the client leaves to ensure this has been completed.
This corrective action will be in place by July 18, 2025. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records, the facility failed to complete initial treatment plans according to the agency policy and procedure in seven out of seven records.
According to agency policy and procedures, the preliminary treatment plan is completed at intake, initial treatment plan is completed within 7 days, and all additional updates are done every 30 days thereafter.
Client #1 was admitted December 19, 2024 and discharged May 19, 2025. The initial comprehensive treatment plan was due by December 26, 2024 but not completed until December 27, 2024.
Client #2 was admitted January 21, 2025 and discharged April 30, 2025. The initial comprehensive treatment plan was due by January 28, 2025 but not completed until February 3, 2025.
Client #3 was admitted October 29, 2024 and discharged February 10, 2025. The initial comprehensive treatment plan was due by November 5, 2024 but not completed until November 8, 2024.
Client #4 was admitted October 22, 2024 and discharged February 6, 2025. The initial comprehensive treatment plan was due by October 29, 2024 but not completed until November 4, 2024.
Client #5 was admitted February 25, 2025 and discharged April 30, 2025. The initial comprehensive treatment plan was due by March 4, 2025 but not completed until March 8, 2025.
Client #6 was admitted December 3, 2024 and still a current client. The initial comprehensive treatment plan was due by December 10, 2024 but not completed until December 17, 2024.
Client #7 was admitted February 4, 2025 and still a current client. The initial comprehensive treatment plan was due by February 11, 2025 but not completed until February 15, 2025.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The employee who did not complete these on time is no longer with the agency.
The Clinical Director will set outlook reminders to follow up with the counseling staff to ensure the initial treatment plans are completed within 7 days and the updates completed every 30 days thereafter. The outlook reminders will be set 2 days prior for the initial comprehensive treatment plans. The Assistant Administrator will follow up with the Clinical Director the day before the plans are due to ensure they are completed or will be completed within the 7-day requirement.
This corrective action will be in place by July 18, 2025. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
|
Observations
Based on a review of client records, the facility failed to update an individual treatment plan every thirty days in three of seven records.
Client #1 was admitted December 19, 2024 and discharged May 19, 2025. A treatment plan was completed on February 15, 2025 and an update was due by March 17, 2025 but not completed until March 18, 2025.
Client #3 was admitted October 29, 2024 and discharged February 10, 2025. A treatment plan was completed on November 26, 2024 and an update was due by December 26, 2024 but not completed until December 27, 2024. Another treatment plan was due by January 26, 2025 but not completed until January 27, 2025.
Client #5 was admitted February 25, 2025 and discharged April 30, 2025. A treatment plan was completed March 24, 2025 and an update was due by April 24, 2025 but was not completed prior to discharge.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The employee who failed to complete this timely is no longer with the agency.
The Clinical Director will set outlook reminders to follow up with the counseling staff to ensure they update the initial treatment plan every 30 days. The outlook reminders will be set 7 days prior for the update to be completed. The Assistant Administrator will follow up with the Clinical Director two days before the plans are due to ensure they are completed or will be completed within the 30-day requirement.
This corrective action will be in place by July 18, 2025. |
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.
|
Observations
Based on a review of client records, the facility failed to document an attempted follow up with clients following discharge from the facility in four of six applicable records reviewed.
According to agency policy and procedures, the facility will follow up with non-graduates within 72 hours and graduates within 30 days.
Client #2 was admitted January 21, 2025 and discharged AFA on April 30, 2025. Follow up was due by May 3, 2025 but not completed until May 7, 2025.
Client #4 was admitted October 22, 2024 and administratively discharged on February 6, 2025. Follow up was due by February 9, 2025 but not completed until February 12, 2025.
Client #8 was admitted on May 1, 2025, and discharged AFA on May 12, 2025. Follow up was due by May 15, 2025 but not completed at the time of the inspection.
Client #9 was admitted on October 15, 2024, and administratively discharged on November 19, 2024. Follow up was due by November 22 but not completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The policy for following up calls for non-graduates will be changed to match the follow up calls for graduates at 30 days and not 72 hours. This will be completed by July 31, 2025 by the Executive Director.
The Clinical Director will ensure the Case Manager completes all follow ups within the 30 days. The Case Manager will put reminders into outlook or a calendar to ensure these are completed as required. The Clinical Director will review monthly to ensure all follow ups have been completed and documented in the electronic health record.
|