INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 7, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Good Works Life Recovery 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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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 staff records, the facility failed to document that staff had completed HIV/AIDS and TB/STD training within the required timeframe in one of two applicable staff records.
Staff #4 was hired as a support staff member on June 1, 2021 and was still employed at the time of the inspection. The HIV/AIDS and TB/STD trainings was to be completed by June 1, 2023. The HIV/AIDS training was completed December 31, 2024. There was no documentation that the TB/STD training was completed at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
709.24 Treatment/rehabilitation management
Employee #4 has registered for the TB/STD. He will take the training on February 11, 2025. After employee #4 completes this training, on February 11, 2025, a copy of the certificate will be available in his personnel file on February 11,2025. To ensure this error will not happen again, the Human Resource Director will review new hire files quarterly to ensure all training are scheduled and/or completed to ensure the citation does not occur again. This procedure will ensure all non-clinical staff completes the 4-hour TB/STB within two years of employment.
Documentation will be presented at the next review.
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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 the administrative information, the facility failed to document a policy and procedure for notifying the emergency contact for clients who discharge against facility advice in the detoxification level of care.
Act 41 of 2021, 71 P.S. 613.1(8.1) states Inpatient drug and alcohol treatment facilities must attempt to notify the emergency contact at least once and develop policies and procedures to implement a notification protocol which includes documenting notification attempts.
The facility failed to attempt to notify the emergency contact in one of one applicable records.
Client #4 was admitted on December 4, 2024 and was discharged on December 10, 2024. There was no documentation the emergency contact was notified.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
709.24 Treatment/rehabilitation management
Client #4 was admitted on December 4, 2024, and was discharged on December 10, 2024. There was no documentation the emergency contact person was notified.
An emergency contact form will be completed by day 2 of admission. The client will sign a release of information for their emergency contact person. If the client leaves against the facility's advice, staff on shift will immediately contact the client's emergency contact person to notify them that their loved one left the treatment facility against the facility's advice. Staff who called the emergency contact person will immediately document, on the emergency contact log form, the date and time staff called and spoke with the emergency contact person. If the emergency contact person does not answer, staff will leave a voicemail message that the client left against the facility's advice, if they hear the name of the person being contacted. If the staff does not hear the name of the person, then the staff will leave a voice message stating to have the emergency contact person call the treatment facility back. Staff will document the date and time, on the emergency contact log form, that they left a voicemail message. If staff cannot leave a voicemail message, then staff will document voicemail was not set up when called.
If the client does not have an emergency contact person, then the client will sign a form stating they do not have an emergency contact person to notify and that form will be placed in the emergency contact binder and in the client chart.
The supervisor of Direct Support Staff will monitor by reviewing the emergency contract log monthly.
Documentation will be presented at the next review.
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709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on client records reviewed, the facility failed to provide case consultations in accordance with the facility policy and procedure manual in two of four applicable records.
The facility policy and procedure manual indicate a case consultation to occur every ninety days.
Client #1 was admitted on September 24, 2024 and was still active at the time of the inspection. A case consultation was due to occur no later than December 24, 2024, however this was not completed at the time of the inspection.
Client #6 was admitted on June 3, 2024 and discharged October 25, 2024. A case consultation was due to occur no later than September 3, 2024, however this was not completed until September 10, 2024.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
709.53 Case Consultation Notes
A case consultation policy was implemented. A case consultation will be completed if needed throughout the client's treatment. The Board of Directors approved and signed the new policy for case consultations.
Documentation will be presented at the next review.
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