INITIAL COMMENTS
|
This report is a result of an on-site provisional license follow-up inspection conducted on August 23, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Adappt 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:
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all staff persons received a 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 in three of four applicable personnel record reviewed.Employee #1 was hired as a counselor on August 8, 2022. The HIV/AIDS training and the TB/STD training were due to be completed no later than August 8, 2023. However, the HIV/AIDS training was not completed at the time of inspection.Employee #2 was hired as a counselor on August 22, 2022. The HIV/AIDS training and the TB/STD training were due to be completed no later than August 22, 2023. However, the HIV/AIDS training was not completed at the time of inspection.Employee #4 was hired as a resident monitor on April 5, 2021. The HIV/AIDS training and the TB/STD training were due to be completed no later than April 5, 2023. However, both trainings were not completed at the time of inspection.This is a repeat citation from the February 15, 2022 and February 9, 2023 annual licensing renewal inspections.This finding was discussed with facility staff during the licensing process.
|
Plan of Correction
Employee # 1 completed HIV/AIDS training on 9/7/23. Employee # 2 completed HIV/AIDS training on 9/6/23. Employee #4 completed his HIV/AIDS training on 1/11/23. All employees that are noted during the re-inspection have completed the HIV/STD training. Director of Security who is also in charge of all trainings will ensure that employees complete the HIV/AIDS and TB/STD training within the first year of employment. |
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.
|
Observations
Based on review of client records and the policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services in one of one applicable client record reviewed.The facility's policy and procedure manual stated the emergency contact will be notified when a client leaves against facility advice.Client #11 was admitted on April 5, 2023 and left against facility advice on May 15, 2023. There was no documentation the emergency contact was notified at the time of the inspection. This finding was discussed with facility staff during the licensing process.
|
Plan of Correction
Clinical staff have been instructed to notify any emergency contact within 12 hours of a client leaving the facility AMA. Facility Director will ensure that this is completed and that emergency contacts have been notified. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of patient records, the facility failed to ensure that a copy of a client consent to release information form was offered to the client in one of twelve client records reviewed.Client #9 was admitted on April 18, 2023 and was discharged on June 2, 2023. A release of information form to a mental health provider was signed and dated by the client on April 18, 2023; however, there was no documentation in the record indicating a copy of the form was offered to the client.This is a repeat citation from the February 15, 2022 and February 9, 2023 annual licensing renewal inspections.This finding was discussed with facility staff during the licensing process.
|
Plan of Correction
A staff meeting was held on 9/6/23 and it was discussed that all releases must be either accepted or declined and checked by the client. This will be ongoing. Facility Director will continue to check all charts to ensure that all releases have been offered a copy to the client and it will be checked as such. |
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.
|
Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include case consultation notes, in two of five applicable client records reviewed.Client #8 was admitted on May 3, 2023 and discharged on July 3, 2023. There was no documentation of case consultation notes as of the date of the inspection. Client #12 was admitted on June 6, 2023 and was discharged on July 6, 2023. There was no documentation of case consultation notes as of the date of the inspection.This is a repeat citation from the February 9, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
As of September 29, 2023, all client files will include a case consultation note after a client has been here for 30 days. Facility Director will monitor this by completing 1 week, 30 and close chart reviews. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include follow-up information, in three of four applicable client records reviewed.Client #8 was admitted on May 3, 2023 and was discharged on July 3, 2023. There was no documentation of follow up information as of the date of the inspection. Client #10 was admitted on June 7, 2023 and was discharged on August 7, 2023. There was no documentation of follow up information as of the date of the inspection.Client #12 was admitted on June 6, 2023 and was discharged on July 6, 2023. There was no documentation of follow up information as of the date of the inspection.This is a repeat citation from the February 15, 2022 and February 9, 2023 annual licensing renewal inspections.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director has had and will continue to have staff meetings to remind clinical staff that all follow-ups need to be done within 7 days of discharge. This will be checked during the closed chart review. Facility Director will be responsible for ensuring that all clients have a follow up phone call within 1 week of discharge. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. Plans of correction for not ensuring a copy of a release of information form was offered to the client were submitted and approved by the Department for the February 9, 2023, February 15, 2022 and February 24, 2021, annual licensing inspection. Not documenting that a copy of a release of information form was offered to the client was again found to be a deficiency in the August 23, 2023, provisional follow-up licensing inspection.Plan of correction for obtaining follow-up information was submitted and approved by the Department for the February 15, 2022 and February 9, 2023 annual licensing inspections. Not completing follow-up information was again found to be a deficiency in the August 23, 2023, provisional follow-up licensing inspection.Plan of correction for ensuring staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training were submitted and approved by the Department for the February 15, 2022 and February 9, 2023 annual licensing inspections. Not ensuring staff persons received the minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD training was again to be found a deficiency in the August 23, 2023 provisional follow-up licensing inspection.This is a repeat citation from the February 9, 2023 annual licensing renewal inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director will ensure and monitor that all POC's are being followed. Facility Director will meet with Director of Security to make sure that all employees have completed the HIV/STD and TB/STD within 1 year of employment.
Facility Director will continue to hold monthly staff meetings and trainings with clinical staff ensure that all deficiencies will no longer happen.
Facility Director will also ensure that staff follow up with discharged client within 1 week of discharge. All clinical staff will be reminded that All emergency contacts will be contacted within 12 hours of AMA of the facility.
Facility Director will continue to check all charts weekly and monthly to ensure that all releases have been offered a copy to the client and it will be checked as such.
As of September 29, 2023, all client files will include a case consultation note after a client has been in treatment for 30 days. Facility Director will monitor this by completing 1 week, 30 and close chart reviews.
|