INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 16, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Tradition 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of fire drill records, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings include:
Fire drill records were reviewed from April 2014 through August 2015 on September 16, 2015. The facility's sleeping hours are from 11:00 PM through 6:30 AM. The facility conducted the following fire drills during sleeping hours: April 29, 2014 at 6:18 AM, January 31, 2015 at 6:00 AM and April 29, 2015 at 6:25 AM. A fire drill during sleeping hours was due to be conducted no later than October 31, 2014. The facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire safety coordinator will conduct fire drills monthly, ensuring that once every 6 months, a fire drill is conducted during the sleeping hours. Program Director will review fire drill log monthly to ensure they are being conducted on all shifts, as required. |
709.28(c) 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 shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to obtain a written, informed and voluntary consent from the client that included the specific information to be disclosed and the purpose of disclosure in three of nine client records.
The findings include:
Nine client records were reviewed on September 16, 2015. Nine client records were reviewed for written, informed and voluntary consents from the client. The facility failed to obtain a written, informed and voluntary consent from the client that included the specific information and the purpose of disclosure in client records # 1, 2 and 4.
Client # 1 was admitted into treatment on July 2, 2015. Client # 1 signed a consent to release information form for their physician on July 2, 2015. The consent to release information form did not include the specific information to be disclosed to their physician or the purpose of the disclosure.
Client # 2 was admitted into treatment on July 3, 2015. Client # 2 signed a consent to release information form for their physician on July 3, 2015. The consent to release information form did not include the specific information to be disclosed to their physician or the purpose of the disclosure.
Client # 4 was admitted into treatment on July 20, 2015. Client # 4 signed a consent to release information form for their physician on July 20, 2015. The consent to release information form did not include the specific information to be disclosed or the purpose of the disclosure.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director and Lead Counselors will ensure that consents are being completed properly. Program Director and lead counselors will monitor charts monthly to ensure that all consents include specific information to be disclosed and the purpose of the disclosure, and that consents are placed in the correct service category.All staff (counselors and administrative assistance) will receive a training in October on completing consents- addressing utilization of the appropriate consent and purpose and specific information to be released. Ongoing additional training will be provided as needed.
Program Director and Lead Counselors will review and audit all active client charts for accuracy of consents. New consents will be formulated as needed. |
709.53(a) LICENSURE Complete Client Record
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:
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Observations
Based on a review of client records, the facility failed to document a complete client record including verification that work done by the client at the project was an integral part of his/her treatment and rehabilitation plan in nine of nine client records.
The findings include:
Nine client records were reviewed on September 16, 2015. Nine client records were reviewed for verification that work done by the client at the project was an integral part of his/her treatment plan. The facility failed to document a complete client record including verification that work done by the client at the project was an integral part of his/her treatment and rehabilitation plan in client records # 1, 2, 3, 4, 5, 6, 7, 8 and 9.
Client # 1 was admitted into treatment on July 2, 2015. An individual treatment plan was completed on July 14, 2015. The facility failed to document a complete client record including verification that work done by client # 1 at the project was an integral part of his/her treatment plan.
Client # 2 was admitted into treatment on July 3, 2015. An individual treatment plan was completed on July 17, 2015. The facility failed to document a complete client record including verification that work done by client # 2 at the project was an integral part of his/her treatment plan.
Client # 3 was admitted into treatment on April 3, 2015. An individual treatment plan was completed on April 20, 2015. The facility failed to document a complete client record including verification that work done by client # 3 at the project was an integral part of his/her treatment plan.
Client # 4 was admitted into treatment on July 20, 2015. An individual treatment plan was completed on July 31, 2015. The facility failed to document a complete client record including verification that work done by client # 4 at the project was an integral part of his/her treatment plan.
Client # 5 was admitted into treatment on June 3, 2015 and discharged on August 29, 2015. An individual treatment plan was completed on June 8, 2015. The facility failed to document a complete client record including verification that work done by client # 5 at the project was an integral part of his/her treatment plan.
Client # 6 was admitted into treatment on November 19, 2014 and discharged on May 15, 2015. An individual treatment plan was completed on November 21, 2014. The facility failed to document a complete client record including verification that work done by client # 6 at the project was an integral part of his/her treatment plan.
Client # 7 was admitted into treatment on January 20, 2015 and discharged on April 16, 2015. An individual treatment plan was completed on January 28, 2015. The facility failed to document a complete client record including verification that work done by client # 7 at the project was an integral part of his/her treatment plan.
Client # 8 was admitted into treatment on May 15, 2015 and discharged on July 6, 2015. An individual treatment plan was completed on May 26, 2015. The facility failed to document a complete client record including verification that work done by client # 8 at the project was an integral part of his/her treatment plan.
Client # 9 was admitted into treatment on April 20, 2015 and discharged on June 26, 2015. An individual treatment plan was completed on May 4, 2015. The facility failed to document a complete client record including verification that work done by client # 9 at the project was an integral part of his/her treatment plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Counselors will include components of work therapy in each individual's treatment plan. The counselors will provide a detailed description of the work therapy that is conducted, the time frames associated with the work therapy, and the therapeutic value of participation in the work therapy. Clients will continue to be provided with detailed information on the work therapy requirements in their client handbooks for reference as well.
Counselors have been retrained on the above area and changes have begun to be implemented. Program Director and lead counselor will ensure that work therapy is identified in the treatment plan, prior to signing off on them when completed. The Program Director and lead counselor will ensure all active charts are updated(including #1,#2, #3, #4,#5,#6,#7,and #8). The Program Director and lead counselor will continue to monitor charts randomly on a monthly basis to ensure ongoing progress. Lead counselors will address progress and/or ongoing concerns with counselors during their monthly supervision. The Program Director and Lead Counselor will continue to educate on this area during weekly treatment team meeting. |