INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 16, 2022 through November 17, 2022, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Libertae Family House Libertae, 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the Project/Facility Director in one applicable record reviewed.Employee # 1 was hired as the Project Director and Facility Director on May 4, 2015 and is current in that position. The facility's training year that was reviewed was from July 1, 2021 through June 30, 2022. Employee #1's employee record only documented 10.5 hours of training for the period reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
This deficiency shall be corrected by the following steps:
It is the responsibility of the administrative office manager to track training hours for the project director and facility director.
Administrative office manager will continue to use the training spreadsheet to track and review training hours for the project director/facility director for the current fiscal year. The training hours will be reviewed with the program director/facility director quarterly.
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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 the physical plant inspection on November 17, 2022, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit. When tested, the water in the employee bathroom on the first floor of the Family House was 130 degrees Fahrenheit.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The issue has been corrected. The hot water heater was adjusted to decrease the temperature of water in the employee bathroom to not exceed 120 degrees Fahrenheit. Maintenance staff will monitor all hot water faucets routinely to ensure that the correction is maintained. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on a physical plant inspection on November 17, 2022, the facility failed to clearly indicate exits by the use of signs as the emergency exit on the second floor of the Crossroads building was not labeled.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The issue has been corrected. The emergency exit sign was installed on the second floor.
The maintenance staff will complete an inspection walk through of each building on a monthly basis to identify any deficiencies requiring correction. All items will be logged and reported to administration with a resolution update.
The conditions will be monitored by maintenance and office staff. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
Based on a physical plant inspection on November 17, 2022, the facility failed to light interior exits and stairs at all times as an emergency exit stairwell in the Halfway House was unlit. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The issue has been corrected. The emergency exit stairwell light switch has been encased with a cover so that the switch cannot be turned off, except by removing the cover. The emergency exit stairwell will remain lit.
The maintenance staff will conduct an inspection walkthrough of each building and grounds to identify any areas of deficiency. A log of findings will be kept and an update with resolution will be entered. The log will be submitted to administrative staff.
Responsible staff are maintenance and office manager. |
705.11 (2) (iv) LICENSURE Child care.
705.11. Child care.
(2) Interior space. The residential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based on a physical plant inspection on November 17, 2022, the facility failed to secure all hazardous and poisonous substances and materials with safety latches or locks. The bathrooms in bedrooms 18 and 19 on the third floor of the Family House contained cleaning products that were not secured with safety latches or locks. Additionally, the bathroom in the childcare room contained an aerosol spray. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The issue has been corrected. All hazardous and poisonous substances and materials are now stored in cabinets with safety latches. Staff will inspect all areas for potential hazardous materials when routine room searches are conducted. The aerosol spray in the childcare area will be stored in a latched cabinet out of reach of children. All staff have been advised and instructed accordingly. |
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 client records and discussion with facility staff, the facility failed to follow their written procedures for the management of treatment and rehabilitation services, pertaining to case consultation documentation, in four of four applicable records and failed to follow their policy related to AFA discharges of calling the Emergency Contact within twelve hours in one of two applicable records.Client #1 was admitted on January 20, 2022 and was discharged on May 2, 2022. The case consultation note from April 27, 2022 did not include the participating staff names and titles.Client #2 was admitted on April 21, 2022 and was discharged on June 22, 2022. The case consultation note from May 31, 2022 did not include the participating staff names and titles.Client #4 was admitted on June 23, 2022 and discharged Against Facility Advice (AFA) on August 10, 2022. There was no documentation in the client record that the emergency contact was called. Client #5 was admitted on July 26, 2022 and was active at the time of the inspection. The case consultation note from September 26, 2022 did not include the participating staff names and titles.Client #6 was admitted on August 18, 2022 and was active at the time of the inspection. The case consultation note from September 19, 2022 did not include the participating staff names and titles.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
(A) Libertae is beginning to utilize a new EMR system that will assist with case consultations being signed. The new EMR system will allow for case consultations to be sent directly to participating staff to be reviewed and signed through the system itself.
(B) Staff is expected to document that emergency contact has been notified when a client AFA's. Treatment techs are provided with orientation checklist to which written instructions for AFA protocol will be added ASAP.
The Clinical Director will monitor compliance with this corrective action plan by reviewing documentation of AFA's on a case by case basis. Case consultation documentation will be monitored weekly to ascertain that required signatures have been obtained and the signed document has been entered into the client's record. A quarterly record audit will be completed by the program manager and clinical director. Findings will be discussed in quarterly quality assurance meetings and corrective action put in place whenever deficiencies are detected. |
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.
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Observations
Based on a review of seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in six records reviewed. Client #1 was admitted on January 20, 2022 and was discharged on May 2, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on January 20, 2022, with no client signed consent to release information form signed by the client.Client #2 was admitted on April 21, 2022 and was discharged on June 22, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on April 21, 2022, with no client signed consent to release information form signed by the client.Client #3 was admitted on February 15, 2022 and was discharged on March 16, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on February 15, 2022, with no client signed consent to release information form signed by the client.Client #5 was admitted on July 26, 2022 and was discharged on October 13, 2022. The record contained documentation that personally identifying information was released to the Department of Human Services on July 26, 2022, with no client signed consent to release information form signed by the client.Client #6 was admitted on August 18, 2022 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on August 18, 2022, with no client signed consent to release information form signed by the client.Client #7 was admitted on September 6, 2022 and was active at the time of the inspection. The record contained documentation that personally identifying information was released to the Department of Human Services on September 6, 2022, with no client signed consent to release information form signed by the client.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. Our admissions intake process now includes Consent for the Release of Confidential Information to Pennsylvania Department of Human Services. Our Admissions Manager is now reviewing this form with each client and obtaining consent on day of admission.
Current clients in care will sign this consent form in the office of the Manager of Admission. The consents will be charted in the client's record.
The Program Manager, who supervises the Manager of Admissions, will monitor the completion of this task. |
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the date, event, or condition upon which the consent will expire in six records reviewed.Client #1 was admitted on January 20, 2022 and was discharged on May 2, 2022. The record contained consent to release information forms to the funding source, a treatment provider, pharmacy, lab, and emergency contact signed by the client on January 20, 2022, that were missing the date, event, or condition upon which the consent will expire.Client #2 was admitted on April 21, 2022 and was discharged on June 22, 2022. The record contained consent to release information forms to the funding source, a treatment provider, pharmacy, lab, and emergency contact signed by the client on April 21, 2022, that were missing the date, event, or condition upon which the consent will expire.Client #4 was admitted on June 23, 2022 and was discharged on August 10, 2022. The record contained consent to release information forms to the funding source, a treatment provider, pharmacy, lab, and emergency contact signed by the client on June 23, 2022, that were missing the date, event, or condition upon which the consent will expire.Client #5 was admitted on July 26, 2022 and was discharged on October 13, 2022. The record contained consent to release information forms to the funding source, a treatment provider, pharmacy, lab, and emergency contact signed by the client on July 26, 2022, that were missing the date, event, or condition upon which the consent will expire.Client #6 was admitted on August 18, 2022 and was active at the time of the inspection. The record contained consent to release information forms to the funding source, a treatment provider, pharmacy, lab, and emergency contact signed by the client on August 18, 2022, that were missing the date, event, or condition upon which the consent will expire.This is a repeat citation from the January 5-6, 2022 annual licensing inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The deficiency has been corrected. Our admission intake packet previously had blank space where we hand wrote expiration conditions per each client. We have revised our intake packet to reflect standardized consent expiration conditions in the body of the form.
The consent forms for current clients will be updated and charted in the clients' records. This will be done by the Manager of Admissions. The Program Manager, who supervises the Manager of Admissions will monitor the compliance with this corrective action. |
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 seven client records, the facility failed to ensure that counseling services were provided according to the individual treatment and rehabilitation plans in four records reviewed.Client #1 was admitted on January 20, 2022 and was discharged on May 2, 2022. The treatment plan updates completed on March 20, 2022 and April 20, 2022 indicated the frequency of individual sessions to be weekly; however, no individual sessions were documented as being held between April 15, 2022 and the date of discharge.Client #2 was admitted on April 21, 2022 and was discharged on June 22, 2022. The treatment plan update completed on May 21, 2022 indicated the frequency of individual sessions to be weekly; however, no individual sessions were documented as being held since between June 7, 2022 and the date of discharge.Client #6 was admitted on August 18, 2022 and was active at the time of the inspection. The comprehensive treatment plan completed on September 18, 2022 and the treatment plan update completed on October 18, 2022 indicated the frequency of individual sessions to be weekly; however, no individual sessions were documented as being held the weeks of September 26, 2022, October 24, 2022, and November 7, 2022.Client #7 was admitted on September 6, 2022 and was active at the time of the inspection. The comprehensive treatment plan completed on October 6, 2022 indicated the frequency of individual sessions to be weekly; however, no individual sessions were documented as being held the week of October 3, 2022.This is a repeat citation from the January 5-6, 2022 annual licensing inspection. The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Staff are expected to document when a client has missed any session as "0". Documentation of missed sessions by clients will be recorded as a "Clinical Note" moving forward in the new EMR. Clinical Director will audit and ensure that clients are seen on a weekly basis by therapists. |