INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15-17, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Renewal Treatment 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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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 on October 15, 2019 at the corporate office and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that employees #13 and #4 received at least four hours of TB/STD and other health related topics within the regulatory timeframe.
Employee #13 was hired as a counselor on November 28, 2016 and was due to have the communicable disease trainings no later than November 28, 2017. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
Employee #4 was hired as a counselor on April 16, 2018 and promoted to clinical supervisor on May 20, 2019. Employee was due to have the communicable disease trainings no later than April 16, 2019. There was no documentation in the personnel file of the completion of the TB/STD training as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All Renewal Treatment, Inc. staff shall have TB/STD and other health related training topics within the regulatory time frames. The Clinical Supervisors shall review each Counselor's compliance with training requirements during annual performance appraisal and during completion of each employee's annual training needs assessment. The Clinical Supervisor shall ensure that each employee needing TB/STD or other health related training (or any other required training) are scheduled/registered and complete this training within required time frames. Additionally, the Director of Human Resource and Compliance, or designee shall audit each employee's training file and provide the Clinical Supervisor with bi-annual updates via spreadsheet of each employee's training completion/compliance to aid in the supervision of each employee's training. The Clinical Supervisor has provided the treatment staff with instruction on this deficiency and the regulatory requirements for training. The Clinical Supervisor and Director of Human Resources and Compliance shall have overall oversight for this plan of correction. This plan of correction is in place.
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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection on October 16, 2019 at approximately 4:15pm, the facility failed to contain trash in covered containers preventing the penetration of insects and rodents. The dumpster located behind the building had trash protruding over the top of the dumpster preventing the lids from closing.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc.'s shall be in compliance with all physical plant regulatory requirements including maintaining our dumpsters in a compliant fashion. Renewal Treatment, Inc. has our dumpsters emptied six (6) days a week, all days except Sunday and Holidays. Renewal, Inc. staff with trash removal responsibilities received instruction on this regulatory requirement and this deficiency. Instruction focused on ensuring the dumpsters are filled properly always allowing the lid to be closed properly preventing access by rodents, insects or vermin etc....Renewal, Inc.'s Custodial staff shall perform daily and weekly sanitation/safety inspection to ensure the building and grounds are maintained in a neat, orderly and well maintained manner. Any occurrence of trash protruding from the dumpster shall be reported to the Director of Facilities and immediately corrected. The Director of Facilities shall have oversight responsibilities for this corrective action. This corrective action is in place. |
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 conducted on October 16, 2019, it was observed that counselor room 505 office door had a window that was uncovered, thus allowing unobstructed visual access.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The physical plant of Renewal Treatment, Inc. shall be in regulatory compliance including maintaining window covers on all Counselor's offices. The Counselor who had their office window uncovered received instruction on this requirement and the need to keep the window covered. The window for Room 505 has been covered. Additionally, the Clinical Supervisor has instructed all treatment staff to keep the windows to Counselor's offices and other counseling space covered. The Clinical Supervisor shall be cognizant to check counselor offices for window covers during daily walk-through procedures of the facility. The Clinical Supervisors shall be responsible for the oversight of this plan of correction. This plan of correction is in place. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection on October 16, 2019 at approximately 2:00pm, the facility failed to maintain hot water temperatures below 120F. The eighth floor front women's bathroom sink temperature read 127.3F.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Renewal Treatment, Inc. shall maintain facility water temperatures according to regulatory requirements. Renewal, Treatment Inc.'s Maintenance staff adjusted the thermostat on the hot water heater during the inspection and the water is at the required 120 F temperature. The water temperature shall be tested by the maintenance staff or custodial staff during weekly safety and sanitation inspections with corrective measures being taken when necessary. The Director of Facilities shall ensure that weekly water tests are being completed at the necessary intervals and shall ensure compliance with this plan of correction. This plan of correction is in place. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection on October 16, 2019, the facility failed to maintain bathrooms in a functional, clean and sanitary manner. The sixth floor men's bathroom was missing wall tiles near the floor creating an opening in the wall.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Renewal Treatment, Inc. shall maintain bathrooms in a functional, clean and sanitary manner. The maintenance staff received instruction on this deficiency and repaired the missing floor tiles in the 6th floor bathroom. Renewal Treatment, Inc. shall inspect the facility at least weekly performing sanitation and safety inspections and shall notate any maintenance issues so that they can be corrected. The Director of Facilities shall ensure that weekly sanitation and safety inspections are occurring at the necessary intervals and that corrective actions are occurring. The Director of Facilities shall be responsible for the oversight of this plan of correction. This plan of correction is in place. |
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 on October 15-17, 2019, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5(b) for releases of information in client records #1, 2, 3, 4, 5, 6, and 7.
Client #1 was admitted on September 6, 2019 and was discharged on October 10, 2019. A consent to release form was signed and dated on September 6, 2019 to the funding source that allowed for the release of "other" information.
Client #2 was admitted on August 8, 2019 and was discharged on October 7, 2019. A consent to release form was signed and dated on August 8, 2019 to the funding source that allowed for the release of "other" information.
Client #3 was admitted on February 8, 2019 and was discharged on April 8, 2019. A consent to release form was signed and dated on February 8, 2019 to the funding source that allowed for the release of "other" information.
Client #4 was admitted on March 27, 2019 and was discharged on May 29, 2019. A consent to release form was signed and dated on March 27, 2019 to the funding source that allowed for the release of "other" information.
Client #5 was admitted on March 6, 2019 and was discharged on May 6, 2019. A consent to release form was signed and dated on March 6, 2019 to the funding source that allowed for the release of "other" information.
Client #6 was admitted on September 11, 2019 and was still active at the time of the inspection. A consent to release form was signed and dated on September 11, 2019 to the funding source that allowed for the release of "other" information.
Client #7 was admitted on September 19, 2019 and was still active at the time of the inspection. A consent to release form was signed and dated on September 19, 2019 to the funding source that allowed for the release of "other" information.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall be in compliance with all regulatory requirements regarding consent to release information. Renewal Treatment, Inc. notified the funding source that their consent to release form was out of compliance. Renewal Treatment, Inc. staff removed the "other" from the form and has had all active clients sign the revised form which has been placed in their client case record. The new revised form shall be utilized for all new clients. The Clinical Supervisor provided instruction/training to the Counselor staff in regards to this requirement and the revision to the consent to release form. The Clinical Supervisor shall ensure continued compliance via regular internal file audit. The Clinical Director and Clinical Supervisor shall be responsible for oversight of this corrective action. This plan of correction is in place. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of the facility's policy and procedure manual on October 15, 2019 at the corporate office, the facility failed to include documentation of all the required client rights, including that the facility will not discriminate based on marital status. In addition, in a review of seven client records on October 15-17, 2019, the facility failed to ensure that the client was made aware of all of their rights in client records #1, 2, 3, 4, 5, 6 and 7. The signed acknowledged client rights did not include that the facility will not discriminate based on marital status.
Client #1 was admitted on September 6, 2019 and was discharged on October 10, 2019.
Client #2 was admitted on August 8, 2019 and was discharged on October 7, 2019.
Client #3 was admitted on February 8, 2019 and was discharged on April 8, 2019.
Client #4 was admitted on March 27, 2019 and was discharged on May 29, 2019.
Client #5 was admitted on March 6, 2019 and was discharged on May 6, 2019.
Client #6 was admitted on September 11, 2019 and was still active at the time of the inspection.
Client #7 was admitted on September 19, 2019 and was still active at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Renewal Treatment, Inc. shall be in compliance with all regulatory requirements including maintaining policy and procedure and documentation that our facilities/programs do not discriminate based on marital status. Renewal Treatment, Inc. revised our Consent to Treatment form which includes the Client Bill of Rights ensuring that it included marital status. All active clients have signed the new revised Consent to Treatment form and it has been placed in each client's case record. This new revised form shall replace the old form and shall be used for all new client's in the future. The Clinical Supervisors provided instruction to the Counselors on this deficiency and the changes to the Consent to Treatment and Bill of Rights. The Clinical Supervisor shall ensure continued compliance during regular internal client file audits. The Clinical Director and Clinical Supervisors shall have overall oversight responsibilities for this plan of correction. This plan of correction is in place. |