INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 10, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Colonial 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:
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Plan of Correction
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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 the April 2024 through March 2025 fire drill logs, the facility failed to document whether or not the smoke detector was operative on the September 24, 2024 fire drill.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The policy regarding monthly fire drills was reviewed with the Maintenance Manager. All requirements such as documentation of time, exits, smoke detector operation and methods were reviewed. The Operations Director will complete random audits of facility fire drill logs to ensure compliance. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in one of two applicable client records reviewed.
Per the requirement in the DDAP Licensing Alert 02-21 the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice
Client #8 was admitted to the inpatient non-hospital rehabilitation activity on January 22, 2025, and was discharged against medical advice on February 5, 2025. There was no documentation that the emergency contact was notified of the client's discharge from the facility against medical advice as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Inpatient Clinical Supervisor will review the policy and procedure for notifying the emergency contact of a cleint that leaves treatment against medical advice with the clinical team by 5/14/2025. Quality Assurance Manager will conduct random audits to ensure ongoing compliance with the process. |