INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 1-2, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, ADAPPT 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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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 (SRFSR) form, the facility failed to ensure that employees #3, #6, and #7 received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #3 was hired on 01/16/17 and was due to have the trainings no later than 01/16/18. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee #6 was hired as a direct support professional on 07/14/14 and was due to have the trainings no later than 07/14/16. There was no documentation in the personnel file of the completion of the HIV/AIDS training and the TB/STD training as of the date of the inspection.Employee #7 was hired as a direct support professional on 07/14/14 and was due to have the trainings no later than 07/14/16. There was no documentation in the personnel file of the completion of the HIV/AIDS training and 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
The Facility Director shall ensure that ADAPPT staff, both clinical and security will attend at least 6 hrs. of HIV/AIDS and 4 hours of TB.STD training within the necessary timeframe.
Berks Aids Network/Co-County Wellness has been contacted and has agreed to present both trainings during the month of August 2018. |
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 05/01-02/18, the facility failed to ensure that counseling sessions could not be seen outside the counseling room. Counselors' offices had windows without window treatments, thus allowing unobstructed visual access.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility provides treatment to individuals involved in the Criminal Justice System.
One of their requirements is that vision panels be provided in offices where staff and clients meet for safety reasons.
Therefore, the facility is submitting an exception request to DDAP allowing for the continued use of the vision panels.
If the exception is not granted, the facility will correct the deficiency so as to be compliant with the DDAP licensing standards. |
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
During the physical plant inspection on May 01-02, 2018, the facility failed to ensure that the water temperature did not exceed 120 degrees. The water temperature in male shower room read 136 degrees and the water temperature in the female restroom read 132 degrees. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ADAPPT Maintenance personnel has corrected the water temperature to be within the proper range.
Maintenance personnel shall continue to test the water temperature to ensure temperature compliance. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
During a review of staff records, the facility failed to document a date of completion for fire extinguisher training for staff # 5. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager shall ensure that all staff, upon employment, are presented with a training on the use of fire extinguishers. Completion will be documented on the individual's training plan.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log conducted on May 1-2, 2018, the facilty lacked documentation that a fire drill for the month of July had been conducted. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire Drills at ADAPPT are held once a month on random shifts to insure that staff on all shifts can respond in an effective and timely manner. Documentation of same shall be found in a Log Book located at each duty desk.
Documentation of the July fire drill was misplaced at the time of the audit.
The Manager of Operations (or designee) shall make periodic checks of the Log Book to ensure that documentation of fire drills can be found at every duty desk. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
During a review of staff records, the facility failed ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.There was no documentation of the date staff person # 5 was trained on assigned duties for emergencies. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All ADAPPT Staff are required to be trained to perform assigned tasks during emergencies.
This training takes place on site during the first 15 days of hire and also occurs during the required 1-2 week Dept. of Corrections Basic Training.
A certificate of completion is provided by the Department of Corrections and the "on the job" training is listed in the employee training file.
Staff person #5 has completed training on assigned duties for emergencies and a copy of the Training Certificate indicating completion of training has been placed in the training file for staff person #5.
The Facility Director/designee shall ensure compliance of this requirement. |
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 the fire drill log conducted on May 1-2, 2018, the facilty lacked documentation that they conducted a fire drill during sleeping hours at least every six months.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Operations Manager/Designee shall ensure that fire drills are held once a month on random shifts to insure that staff on all shifts can respond in an effective and timely manner.
The Log Book for the evacuation drill shall be found at the duty desks and contain the following information: who conducted the fire drill, the date, time needed for completion, and the number of people involved. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of staff records the facility failed to document an annual work performance evaluation for staff persons #2,3, and 5.Staff #2 with a hire date of 8/23/93 did not have documentation of a current annual performance evaluation.Staff #3 with a hire date of 1/16/17 did not have documentation of an annual performance evaluation.Staff #5 with a hire date of 12/22/14 did not have documentation of a current annual performance evaluation.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
ADAPPT Staff Performance Evaluations shall be completed at least annually according to policy.
The Facility Director/Designee shall ensure that all 2018 Staff Performance evaluations be completed by end of year 2018.
The 2018 Performance Evaluation for Staff#2 has been completed and a copy of same has been placed in the personnel file.
Performance evaluations for Staff #3 and Staff #5 shall be completed within the next 6 months according to GEO policy. Copies of the completed evaluations shall be placed in the individual's personnel file. |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on a review of 7 client records, 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 record #'s 1, 2, 3, 4, 5, 6, and 7. The findings include: A consent form labled "Authorization to Disclose Health Information" releasing information to government agencies allowed for the release of medication list, Treatment plans/ Assessments Medication list, Progress reports (treatment, program related), other, List of allergies, Immunization record, most recent discharge plan. Consent to release information forms in client records, #1,2, 3, 4, 5, 6, and 7 were missing the specific information to be released and the purpose of the disclosure.Client #1 was admitted on 4/18/18 and was an active client as of the date of the inspection. A consent to release form was signed and dated on 4/20/18 to government agencies. On 4/18/18 a release form was signed stating "some level of communication" for purpose of disclosure Client #2 was admitted on 3/23/18 and was an active client as of the date of the inspection. A consent to release form was signed and dated on 3/22/18 to government agencies. On 3/23/18 a release form was signed stating "some level of communication" for purpose of disclosure. The client record contained a consent form dated 3/23/18 to a government agency did not have an expiration date provided.Client #3 was admitted on 4/23/18 and was an active client as of the date of the inspection. A consent to release form was signed and dated on 4/24/18 to government agencies. On 4/23/18 a release form was signed stating "some level of communication" for purpose of disclosure. Client #4 was admitted on 4/12/18 and was an active client as of the date of the inspection. A consent to release form was signed and dated on 4/12/18 to government agencies. A consent form to release information dated 4/12/18 to a third party payer states "some level of communication" for purpose of disclosure.Client #5 was admitted on 9/28/17 and was discharged on 11/17/17. A consent to release form was signed and dated on 9/30/17 to government agencies. A consent form to release information dated 9/28/17 to a third party payer states "some level of communication" for purpose of disclosure.Client #6 was admitted on 10/23/17 and was discharged on 12/26/17. A consent to release form was signed and dated on 10/23/17 to government agencies. . A consent form to release information dated 10/23/17 to a third party payer states "some level of communication" for purpose of disclosure.Client #7 was admitted on 9/11/17 and was discharged on 10/10/17. A consent to release form was signed and dated on 9/12/17 to government agencies. A consent form to release information dated 9/11/17 to a third party payer "some level of communication" for purpose of disclosure. Consent form also indicated refused and accepted to be checked off.The findings were reviewed with facility staff during the licensing inspection
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Plan of Correction
ADAPPT shall obtain informed and voluntary consent for the disclosure of information contained in the client record.
No information shall be released on any ADAPPT client without a fully completed written, signed, and voluntary consent listing the name of the person, agency, or organization to whom the disclosure is being made, the specific information to be disclosed (within the guidelines of PA Code 255.5 and Federal Law 42 C.F.R. Part II)the purpose of the disclosure, dated signature of the client, dated signature of a witness, and the expiration date of the release.
The Clinical Supervisor shall present a training to counseling staff on the proper completion of client releases.
Counselor files will be audited periodically by the Clinical Supervisor and Facility Director to ensure compliance. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
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Observations
Based on a review of 7 client records, the facility failed to provide a complete client record, which is to include a Medical history, drug or alcohol history, personal history, physical examination, psychosocial evaluation, discharge summaries, aftercare plans, case consultation notes, and follow-up information in client record #'s 3, 4, and 5.Client # 3 was admitted on 4/24/18 and records indicate a Biopsychosocial dated 4/24/18 that had copied and pasted information in the assessment.Client #4 was admitted 4/12/18 and records have no documentation of a completed psychosocial evaluation, physical exam, medical history, drug and alcohol history, or personal history.Client # 5 was admitted 9/28/17 and was administratively discharged on 11/17/17. Facility failed to document a termination letter in client records. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor has met with counseling staff to re-affirm that a Biopsychosocial always needs to be individualized, completed in the required timeframe, and is never to be copied and pasted.
The Clinical Supervisor has presented a training to all Clinical Staff regarding client charting and timeframes and has had each counselor sign off on an acknowledgement of responsibility of duties and appropriate timeframes.
An undetermined number of Client files shall be audited by the Clinical Supervisor on a weekly basis. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of 7 client records, there was no documentation that the clients received counseling services according to their individual comprehensive treatment plan in 4 charts reviewed.Client #1 was admitted on 4/18/18 and was still active at the time of the inspection. The comprehensive treatment plan indicated 1 30 minute individual session and 2 group sessions per week. Client records show 1 individual session occurred on 4/23/18 with no record of group sessions. Client #4 was admitted on 4/12/18 and was still active at the time of the inspection. The comprehensive treatment plan indicated 1 30 minute individual session and 2 group sessions per week. Client records show 1 individual session on 4/23/18 with no record of group sessions. Client #5 was admitted on 9/28/17 and was discharged on 11/17/17. The comprehensive treatment plan indicated 1 30 minute individual session and 2 group sessions per week. Client records show 1 individual session completed with no record of group sessions.Client #7 was admitted on 9/11/17 and was discharged on 10/10/17. The comprehensive treatment plan indicated 1 30 minute individual session and 2 group sessions per week. Client records show individual sessions completed and 1 group note.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The deficiencies related to counseling services and documentation were discussed with clinical staff during a clinical staff meeting held in the Clinical Supervisor's office. The following plan of correction was developed. Individual treatment and rehabilitation plans shall at all times include the frequency of treatment services.
The Clinical Supervisor shall ensure that all charts are reviewed and signed at least every 30 days to ensure all necessary documentation of counseling services is found in the client file. |
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 seven client records, the facility failed to provide a complete client record in five of seven records reviewed.Client #1 was admitted on 4/18/18 and the facility failed to document a record services provided. Client #2 was admitted on 3/23/18 and the facility failed to document a record of services provided. Client #4 was admitted on 4/12/18 and the facility failed to document a record services provided. Client # 6 was admitted on 10/23/17 and successfully discharged on 12/26/17. Facility failed to document a discharge summary and follow up.Client #7 was admitted on 9/11/17 and discharged on 10/10/17 and the facility failed to document a record services provided and a discharge summary.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor has met with all counseling staff to stress the importance of the required documentation to be found in client files, e.g. Records of Service, etc.
A training has been presented to counseling staff by the Clinical Supervisor. All staff have been advised that client files shall be audited by the Clinical Supervisor on a routine basis to ensure completion of timely paperwork. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on review of 7 client records, the facility failed to document how work done by the client at the project is an integral part of his treatment and rehabilitation plan. Client #1 was admitted on 4/18/18 and the facility failed to document verification of work being done as part of the treatment and rehabilitation plan.Client #2 was admitted on 3/23/18 and the facility failed to document verification of work being done as part of the treatment and rehabilitation plan.Client #3 was admitted on 4/24/18 and the facility failed to document verification of work being done as part of the treatment and rehabilitation plan. Client #4 was admitted on 4/12/18 and the facility failed to document verification of work being done as part of the treatment and rehabilitation plan.Client #5 was admitted on 4/24/18 and discharged on 11/17/17 and the facility failed to document verification of work being done as part of the treatment and rehabilitation plan.Client # 6 was admitted on 10/23/17 and successfully discharged on 12/26/17 and the facility failed to document verification of work being done as part of the treatment and rehabilitation plan.Client #7 was admitted on 9/11/17 and discharged on 10/10/17 and the facility failed to document verification of work being done as part of the treatment and rehabilitation plan.These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Supervisor has reviewed Chart responsibilities with clinical staff, and shall continue to re=enforce the importance of required client charting.
All client charts shall include document verification of work being done as part of the treatment and rehabilitation plan.
The clinical Supervisor shall audit client files for accuracy and completion on a weekly basis. |