INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance Prevention and Treatment on August 6-7, 2019. Based on the findings of the on-site inspection, Gratitude House was found to not 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)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
The facility failed to provide CPR and First Aid Training to a sufficient number of staff persons so that at least one person trained in these skills is onsite during the project's hours of operation. Staff #11 was hired on February 8, 2019. Staff #11 was not trained in CPR and First Aid. Staff #11 worked the midnight to 8am shifts alone on the following dates: June 9, 2019, June 15, 2019, June 16, 2019, June 22, 2019, June 23, 2019, June 29, 2019, June 30, 2019, and July 6, 2019. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from July 18, 2018.
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Plan of Correction
Program Director and BH Tech Supervisor will ensure that all shifts are covered by at least one employee who is CPR/first aid certified. Program Director and BH Tech Supervisor will monitor compliance via obtaining a copy of all employees CPR/first aid cards and comparing these to the staff schedule on a monthly basis. Any employee who is due for CPR/first aid recertification will be scheduled by BH Tech Supervisor and reminded of the training. BH Tech Supervisor will follow up with Human Resources following each training to ensure that the employee completed the required training. Staff #11 was trained in CPR/First Aid on 8/14/19.
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705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
During a physical site inspection on August 7, 2019, the bathtubs and showers in the facility did not have slip-resistant surfaces. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance put slip-resistant mats in all facility bathrooms on 8/8/19. Maintenance, Housekeeping, and Executive Director will monitor to ensure they remain clean, sanitized, and in place weekly. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
During a site inspection on August 7, 2019, the facility failed to ensure that all bathrooms were ventilated by an exhaust fan or window. The ventilation fans in both basement bathrooms were inoperable. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
New exhaust fans were installed in both basement bathrooms on 8/7/2019. Maintenance will monitor that all bathroom fans are operable at all times. |
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
During a site inspection on August 7, 2019, the facility failed to maintain each bathroom in a functional, clean and sanitary manner at all times. The showers in the facility had moldy and mildewed shower curtains. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All bathroom shower curtains were replaced on 8/8/19. Housekeeping will monitor bathrooms weekly to ensure cleanliness and sanitized at all times. |
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
During a review of facility fire drill logs on August 6-7, 2019, the facility failed to conduct unannounced fire drills at least once a month. There was no fire drill documented for the month of July 2018. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed with maintenance and staff on 8/8/19 regarding regulations for fire drills being conducted monthly. Executive Director will review fire drill logs monthly to ensure completion. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
During a review of facility fire drill logs on August 6-7, 2019, the facility failed to prepare alternate exit routes to be used during fire drills. The facility documented the use of the same exit route for all fire drills for the past year. All fire drills from August 2018 through July 2019 documented use of the side exit only. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed regulations for fire drills and use of alternative evacuation routes on a monthly basis. This was discussed in staffing on 8/27/19. Program Director will monitor monthly fire drill logs to ensure compliance. |
709.1-709.5 LICENSURE Subchapter A. General Provisions
Chapter 709. Standards for Licensure of Freestanding Treatment Activities
709.1. Scope.
(a) This chapter establishes the procedures for the issuance of a license by activity to freestanding drug and alcohol treatment facilities. The term, facility, applies to the physical location from which drug and alcohol services are provided. A facility may provide more than one service.
(b) This chapter provides standards by activity for the licensure of freestanding drug and alcohol treatment facilities, under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059).
709.2. Policy.
(a) Persons, partnerships and corporations, or other legal entities intending to provide drug and alcohol treatment services, shall first be licensed by the Department.
(b) No drug or alcohol freestanding treatment facilities may receive funds from the Department without a license issued under this chapter.
709.3. Legal base.
The authority of the Department to license drug and alcohol treatment activities is established under the powers and duties contained in Articles IX and X of the Public Welfare Code (62 P. S. Subsections 901-922, 1001-1031, and 1051-1059) as transferred to the Department by Reorganization Plan No. 2 of 1977 (P.L. 372) (71 P. S. subsection 751-25) and No. 4 of 1981 (P. L. 610) (71 P. S. subsection 751-31).
709.4. Exceptions.
(a) The Department may, within its discretion, and for good reasons, grant exceptions or extensions of time to this chapter when the policy objectives of this chapter are met, but no exception may be granted which contravenes the authorizing statute.
(b) The project director shall submit a written request for an exception which shall include the approval of the governing body.
(c) Exceptions will not be granted for a situation in which a provisional license would be appropriate.
709.5. Revocation of exceptions.
(a) An exception granted under this chapter may be revoked by the Department. Notice of revocation will be in writing and include the reason for the action of the Department and a specific date upon which the exception will be terminated.
(b) In revoking an exception, the Department will provide for a reasonable time between the date of written notice of revocation and the date of termination of an exception for the project to come into compliance with this part.
(c) If a project wishes to request a reconsideration of a denial or revocation of an exception, it must do so in writing to the Department within 30 days of receipt of the adverse notification.
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Observations
During a Project Wide review of the Policy and Procedures, the project failed to include sex and marital status in the Client Rights policy.709.30 (2), and also the project failed to include documentation of the reasons for removing sections from the record. 709.30 (3). These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The new form to be added to Carelogic for all programs by September 1, 2019. Program Director will ensure all staff are educated on the new forms by September 15,2019. |
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
During a review of client records on August 6, 2019, the facility failed to notify clients of all their civil rights in seven out of seven records. Client #1 was admitted on May 17, 2019 and was current at the time of the inspection. Client #1 was not notified that the project may not discriminate on the basis of sex and color. Client #2 was admitted on April 23, 2019 and was current at the time of the inspection. Client #2 was not notified that the project may not discriminate on the basis of sex and color. Client #3 was admitted on April 4, 2019 and was current at the time of the inspection. Client #3 was not notified that the project may not discriminate on the basis of sex and color. Client #4 was admitted on March 6, 2019 and was discharged on April 14, 2019. Client #4 was not notified that the project may not discriminate on the basis of sex and color. Client #5 was admitted on February 4, 2019 and was discharged on March 18, 2019. Client #5 was not notified that the project may not discriminate on the basis of sex and color. Client #6 was admitted on March 5, 2019 and was discharged on May 6, 2019. Client #6 was not notified that the project may not discriminate on the basis of sex and color. Client #7 was admitted on January 9, 2019 and was discharged on May 17, 2019. Client #7 was not notified that the project may not discriminate on the basis of sex and color. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Forms Committee will be updating the form in Carelogic to include the missing information. The new form to be added to Carelogic for all programs by September 1,2019. Program Director will ensure all staff are educated on the new form by September 15,2019. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The project failed to file a written unusual incident report with the Department within three business days following an unusual incident involving the presence of police, fire or ambulance personnel. There was an unusual incident documented on August 2, 2019 involving the use of ambulance services to transport a client to the emergency room. This unusual incident was not submitted to the Department of Drug and Alcohol Programs as specified in the regulations. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director reviewed protocol for reporting unusual incidents during clinical meeting on August 27, 2019. Reviewed forms to be completed and faxed within 72 hours of incident. Lead counselors and program director will be responsible for completion of reports. All incident reports upon completion will be uploaded to Pyramid Smartsheet, to be reviewed for accuracy and completion by Clinical Compliance team. Program Director and risk committee will review onsite incident reports weekly to ensure proper unusual incident reports are completed. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
During a review of client records on August 6-7, 2019, the facility failed to review, and update treatment and rehabilitation plans every thirty days. Client #2 was admitted on April 23, 2019 and was current at the time of inspection. Client #2 had an initial treatment and rehabilitation plan on April 23, 2019 and a comprehensive treatment and rehabilitation plan on May 23, 2019. Client #2 should have had a treatment and rehabilitation plan update no later than June 23, 2019 but did not have one until July 4, 2019. Client #2 then had another update on July 17, 2019. Client #3 was admitted on April 4, 2019 and was current at the time of inspection. Client #3 had an initial treatment and rehabilitation plan on April 4, 2019 and did not have a comprehensive treatment and rehabilitation plan until June 7, 2019. Client #3 did have treatment and rehabilitation plan updates on July 14, 2019 and July 29, 2019. Client #5 was admitted on February 4, 2019 and was discharged on March 18, 2019. Client #5 had an initial treatment and rehabilitation plan on February 4, 2019 and then had no further documented treatment and rehabilitation plansThese findings were reviewed with facility staff during the licensing process. This is a repeat citation from July 18, 2018.
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Plan of Correction
Program Director conducted a clinical training on August 27,2019 to review treatment plan regulations and current deficiencies. All current clinical staff attended the training. Program Director and Lead Counselor will monitor ongoing progress and compliance through monthly chart audits. Ongoing issues regarding compliance will be addressed individually with clinicians during their monthly supervision. The next chart audits will be conducted by September 2,2019. |
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
The facility failed to provide counseling services according to the individual treatment and rehabilitation plan. Client #2 was admitted on April 23, 2019 and was current at the time of the inspection. Client #2 had treatment plans on April 23, 2019, May 23, 2019, July 4, 2019 and July 17, 2019 stating that they should be receiving individual therapy bi-weekly. Client #2 only had documented individual therapy on the following dates: May 23, 2019, July 1, 2019, July 4, 2019, July 17, 2019 and August 2, 2019. Client #3 was admitted on April 4, 2019 and was current at the time of the inspection. Client #3 had treatment plans on April 4, 2019, June 7, 2019, July 4, 2019 and July 29, 2019, stating that they should be receiving individual counseling bi-weekly. Client #3 only had documented individual therapy on the following dates: July 4, 2019, July 15, 2019 and July 29, 2019. Client #4 was admitted on March 6, 2019 and was discharged on April 14, 2019. Client #4 had treatment plans on March 7, 2019 and April 4, 2019 stating that they should be receiving individual therapy bi-weekly. There was no documentation of any individual therapy for Client #4. Client #5 was admitted on February 4, 2019 and was discharged on March 18, 2019. Client #5 had a treatment plan on February 4, 2019 stating that they were to receive individual therapy bi-weekly. It was noted that the Client #5 had an individual counseling session on February 6, 2019, however the DAP note was blank with no documentation of the counseling session. These findings were reviewed with facility staff during the licensing process. This is a repeat citation from July 18, 2018.
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Plan of Correction
Program Director and Lead Counselor will ensure that individual sessions are provided bi-weekly, via chart audits. Program Director and Lead Counselor will review any ongoing issues with clinicians during monthly supervision. Next chart audit will be 9/02/19. |