INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 8, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Peace and Harmony House 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, the facility failed to ensure all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics training within the regulatory timeframe in one of four applicable personnel records reviewed.
Employee # 3 was hired as a counselor on March 25, 2024 and was due to have the HIV/AIDS training and the TB/STD training no later than March 25, 2025. There was documentation showing the employee completed the required hours for the HIV/AIDS training, but there was no documentation indicating the TB/STD training was completed 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
Effective immediately, several steps will be implemented. First, a digital Training Compliance Tracker will be developed and maintained by executive assistant. This tracker will monitor each staff member's mandatory trainings completed and making sure all mandatory trainings are scheduled within one year.
To further support timely training, the Clinical Super will develop and distribute a monthly staff training calendar. This calendar will list mandatory training each counselor and counselor assistant must complete. Lastly, to ensure continued compliance,Executive Assistant will conduct monthly audits of training records. Employee #3 has completed the tb/std training on 4/10/2025 she was not able to get into another one before that date. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be disclosed on release of information forms in one of seven client records reviewed.
Client # 6 was admitted on May 8, 2024 and was discharged on July 18, 2024. The release of information forms to an external provider and an emergency contact were signed and dated by the client on June 4, 2024; however, both release forms had "other" as the specific information to be disclosed and the corresponding space to indicate what that specific information was had been left blank.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, all current ROI forms where "Other" was selected without clarification will be reviewed and amended where appropriate. The Clinical Supervisor will audit all such forms for accuracy within 24 hours of a client signing the release. If any missing or vague descriptions are identified, corrective documentation will be completed within 24 hours of the client's signature date. This immediate review process ensures that all releases are specific, valid, and legally compliant. To prevent recurrence, a standardized protocol will be implemented for staff completing ROI forms. A brief in-service training will be conducted by the Clinical Director by May 7, 2025, emphasizing the importance of clearly specifying what is being disclosed when "Other" is checked. Staff will be instructed that vague terms (e.g., "other info") are not acceptable, and examples of acceptable entries will be provided. Additionally, a checklist will be added to the intake and documentation review process to ensure that all ROIs are properly completed before being processed. Supervisors will verify this as part of their routine documentation audits. These audits will occur weekly and include all of recently signed ROIs |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update each client's treatment plan at least every 60 days in three of seven client records reviewed.
Client #1 was admitted on January 30, 2025 and was still active at the time of the inspection. The comprehensive treatment plan was completed on February 5, 2025 and the first update was due no later than April 5, 2025; however, the update was not completed as of the date of inspection.
Client #2 was admitted on December 10, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was completed on January 8, 2025 and the first update was due no later than March 8, 2025; however, the update was not completed by the clinician until April 6, 2025.
Client #7 was admitted on June 25, 2024 and was discharged on October 4, 2024. The comprehensive treatment plan was completed on July 11, 2024 and the first update was due no later than September 11, 2024; however, the update was not completed by the clinician prior to discharge
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, all clinical supervisors will audit treatment plan timelines during their weekly individual supervision meetings with counselors. Additionally, any treatment plans that are due for a 60-day update will be brought to the weekly clinical team meeting, for review, discussion, and follow-up. This will allow supervisors and the clinical team to monitor due dates in real time and provide additional accountability and support. Effective Immediately, all caseloads will be reviewed weekly by supervisors during supervision to track treatment plan deadlines and ensure compliance. A treatment plan tracking sheet will be developed for each counselor to aid in the process, with initial templates distributed by May 10, 2025. To address prevention from the start of treatment, all Master Treatment Plans for new clients will be reviewed by a clinical supervisor within 24 hours of completion. This early oversight ensures supervisors are aware of each client's plan cycle and can guide staff accordingly. Treatment Plan was completed on 4/6/2025 due to that being her next appointment. |