INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 18, 2017 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Salvation Army Harbor Light Center 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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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
The facility failed to document that a client was notified, in writing, of a decision to involuntarily terminate the client ' s treatment at the project in one of one client record reviewed on April 18, 2017.
Client # 9 was involuntarily terminated on 4/2/17. There was no documentation that the client had been notified, in writing, of the decision.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The program will implement a protocol that the director will implement when an administrative discharge is warranted:
*if the client is being asked to leave then the director will meet with the client and discuss the discharge as well as provide him a letter describing reason for discharge and the process to appeal this.
* if the client leaves the program without notice, then a discharge letter will be mailed to the clients last know n address describing the discharge. |
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
The facility failed to document physical examinations in two of nine client records reviewed on April 18, 2017.
Nine records were reviewed and physical examinations were required in all nine. There was no documentation of a physical examination in client records # 3 and 5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A protocol has been implemented that includes:
* confirming that a referring provider documentation that the client had a recent physical by a physician or nurse.
* If the client does not have this document upon admission, then we as the provider will refer the client to a local physician who can complete a physical form for our records.
Intake case manager will be the primary person responsible for this duty and Director will also complete ongoing chart assessments to make sure this continues to happen consistently |