INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 4, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Britelife Recovery at Hanover LLC 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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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.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report form, the facility failed to ensure that employees received a minimum of six hours of HIV/AIDS and at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #8 was hired as a lead housekeeper on April 11, 2022 and was due to have the communicable disease trainings no later than April 11, 2024. The HIV/AIDS trainings was completed on September 26, 2024 and the TB/STD training was completed on October 8, 2024.
Employee #9 was hired as a behavior health tech on July 18, 2022 and was due to have the communicable disease trainings no later than July 18, 2024. The HIV/AIDS trainings was completed on October 8, 2024.There was no documentation of the TB/STD training being completed.
Employee #10 was hired as a maintenance tech on August 23, 2021 and was due to have the communicable disease trainings no later than August 23, 2023. The HIV/AIDS trainings was completed on October 21, 2024.There was no documentation of the TB/STD training being completed.
Employee #11 was hired as a behavior health tech on August 1, 2022 and was due to have the communicable disease trainings no later than August 1, 2024. The HIV/AIDS trainings was completed on October 18, 2024.There was no documentation of the TB/STD training being completed.
Employee #12 was hired as a behavior health tech on July 18, 2022 and was due to have the communicable disease trainings no later than July 18, 2024. The TB/STD training was completed on October 8, 2024.
Employee #13 was hired as a maintenance tech on June 20, 2022 and was due to have the communicable disease trainings no later than June 20, 2024. The HIV/AIDS trainings was completed on October 28, 2024.There was no documentation of the TB/STD training being completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All of the staff members that haven't yet completed the communicable disease trainings are now scheduled to complete these trainings. A training schedule with due dates has been developed for all departments to ensure compliance with timeliness for completion. Executive Director will be tracking to ensure compliance with training due dates. This corrective action began on 11/5/2024 and will be on-going until all employees have met the training requirements. |
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 rooms.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The cameras have since been turned off and are not currently being utilized. A request for exception has been submitted through the appropriate DDAP contact. |
705.9 (4) (ii) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(4) Provide written procedures for staff and residents to follow in case of an emergency which shall include provisions for:
(ii) Assignments of staff during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and personnel records, the facility failed to ensure one employee received the required training to perform assigned tasks during emergencies upon hire.
Employee #6 was hired on February 20, 2024 for the position of counselor and was still employed at the time of the inspection. The emergency training occurred on October 23, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
It is protocol that emergency planning training is completed within 48-hours of an employees start date. A re-training with the Director of Operations, who reviews this information, was completed on 11/5/2024 to ensure that emergency planning training is completed during this portion of the new hire orientation. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill logs from December 2023 - through October 2024, the facility failed to maintain a written fire drill record including the number of persons in the facility at the time of the drill on the August 19, 2024 fire drill log.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A retraining was done on 11/5/2024 by Executive Director with the Director of Operations to retrain on the process of fire drill logs and proper documentation. Director of Operations will be submitting monthly Fire Drill Logs to Executive Director. ED will ensure proper completion of the process and documentation on a monthly basis. |
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 one out of one applicable client record.
Client #6 was admitted on June 6, 2024 and discharged on June 20, 2024.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Policy was reviewed by Executive Director as reminder and retraining. Termination letters will be completed and sent to clients that have been terminated from treatment and the written letter will be uploaded to their EMR chart. This will be audited by the Executive Director and Clinical Director on a monthly basis. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in five out of seven client records reviewed.
Client #1 was admitted on October 12, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 19, 2021 with no frequency identified.
Client #2 was admitted on October 13, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 20, 2024 with no type identified.
Client #3was admitted on October 21, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 26, 2024 with no type or frequency identified.
Client #5 was admitted on June 9, 2024 and discharged on July 3, 2024. A comprehensive treatment plan was developed on June 6, 2024 with no frequency identified.
Client #6 was admitted on June 6, 2024 and discharged June 20, 2024. A comprehensive treatment plan was developed on June 5, 2024 with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Procedure was reviewed and retrained with Clinical Director on 11/5/2024. A retraining for the Clinical Team is scheduled for 12/10/2024. Corrective action will be completed by 12/10/2024 and will be audited monthly by Clinical Director and reviewed by Executive Director and Chief Clinical Officer. |
709.53(a)(8) LICENSURE Case Consultation 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:
(8) Case consultation notes.
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Observations
Based on a review of inpatient rehab client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy and procedures manual states that case consultations must be completed weekly.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
A retraining was completed with Clinical Director on 11/5/2024. A new system for Case Consultation was developed by Executive Director and implemented starting 11/13/2024. Executive Director will be auditing charts monthly to ensure that case consultations are being completed as expected. |
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 client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of two applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed seven days following discharge.
Client #5 was admitted on June9, 2024 and discharged on July 3, 2024. No follow up was completed.
Client #6 was admitted on June 6, 2024 and was discharged on June 20, 2024. No follow up was completed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A retraining was completed with the Client Care Supervisor on 11/5/2024. Client Care Supervisor completed a retraining with Case Managers on 11/6/2024. Client Care Supervisor will be auditing charts weekly to ensure that follow up is being completed and documented as expected. |