INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 8, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Drug and Alcohol Rehabilitation Services 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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705.3 LICENSURE Living rooms and lounges.
705.3. Living rooms and lounges.
The residential facility shall contain at least one living room or lounge for the free and informal use of clients, their families and invited guests. The facility shall maintain furnishings in a state of good repair.
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Observations
Based on a physical plant inspection, the facility failed to maintain furnishings in a state of good repair in the client lounge located in room 317. A couch in lounge room 317 had a tear and was in disrepair.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The couch in room 317 was discarded and replaced.
During weekly facility checks, the Maintenance Supervisor will inspect for any damaged furniture in all client areas.
Damaged items will be removed from use and repaired or replaced as needed. |
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, the facility failed to ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room.
A counseling office in the counseling hallway could be seen and heard from another office.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Individual clinical offices are located next to and across from each other on the clinical floor. The conversation overheard was related to a phone conversation between a client and his family, while the counselor's office door was open. All clinical staff have been instructed by the Clinical Director that office doors must be shut when clients are present in the office. This will be included in orientation information for newly hired counselors to prevent recurrence of overheard client conversations. |
705.5 (a) (1) LICENSURE Sleeping accommodations.
705.5. Sleeping accommodations.
(a) In each residential facility bedroom, each resident shall have the following:
(1) A bed with solid foundation and fire retardant mattress in good repair.
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Observations
Based on a physical plant inspection, mattresses located on the 4th floor were not in good repair. Multiple bedrooms on the 4th floor had mattresses that were torn and in disrepair.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to the impact of COVID on census numbers, the 4th floor bedrooms have not been used for approximately 18 months. However, all mattresses on this unused floor that were torn have been discarded and replaced. All active 3rd floor client bedrooms are furnished with new mattresses that were purchased in March 2021.
As part of the client discharge procedure, the Maintenance Supervisor will inspect the mattress of the discharging client for damage. Any damaged mattresses will be removed from the bedroom for repair/replacement. |
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 a physical plant inspection, the water temperature exceeded 120 degrees in the third floor bathroom. The temperature read 138 degrees.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The commercial boiler used to provide hot water to our buildings has a holding tank with an auxiliary heating unit that is set to maintain water at 120 degrees F. We will ensure that the temperature remains consistent for all domestic hot water circulating through the buildings.
The Maintenance Supervisor and Executive Director will ensure that water temperatures do not exceed 120 degrees Fahrenheit via weekly building walkthroughs.
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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
Based on a physical plant inspection, the bathroom exhaust fan was inoperable in the bathroom where urinalysis specimens are provided.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The vent in this bathroom will be replaced with an electric ventilation fan. The Maintenance Supervisor will be responsible for ensuring that all ventilation fans are operable in all bathrooms throughout the facility.
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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
Based on a physical plant inspection, the bathroom on the located on the third floor had shower walls that had paint peeling off and a faucet with operating water and no spigot.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
An outside contractor specializing in tile-coating and waterproofing floors is scheduled to repair the affected areas on October 15 ? 18, 2021. The Maintenance Supervisor will oversee the completion of this project. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection, the facility failed to store utensils in a clean enclosed area. Cooking utensils were hanging up and in open containers.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Utensils are now located in a sealed container with a closing lid. This will be maintained by the kitchen supervisor and checked daily. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
Based on a physical plant inspection, the facility was not free of insect infestations as the fourth floor was infested with bees and flies. Also, throughout the facility, insects were observed in light fixtures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The insects that were discovered on the unused 4th floor of the facility, in a vacant room, were removed and the point of entry at a small open section of window, was closed. DARS, Inc. maintains a contract with Ehrlich Pest Control to perform bi-weekly insect prevention. Due to this being an unused area of the building, the pest control completed did not include daily cleanings as in all other active areas of the buildings. Cleanings of this area will be scheduled weekly and supervised by the Youthcare Supervisor and inspected weekly by Executive Director.
Light fixtures containing insects were cleaned.
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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 one of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
Client Record # 2 was admitted on February 11, 2021 and discharged on May 11, 2021. Progress reports were released to probation for May 2021, April 2021, March 2021, and February 2021 without an informed and voluntary consent from the client for the disclosure of information.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the policy of DARS, Inc. Manos House that consents for probation or case management upon intake into treatment. In this individual client record, the consent to release information to the client's probation officer was not present. The clinical staff has been informed of this deficiency and have been reminded to ensure proper consents are present in each file.
The Clinical Director remains responsible for checking client records and will review each file prior to monthly progress reports being sent to probation.
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709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on three of seven client records reviewed, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information to keep the specific information disclosed within the limits of 255.5 (b).
Client # 4 was admitted on August 4, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on August 5, 2021 to a probation officer allowed for the release of discharge summary, aftercare plan and progress reports. Also, a correspondence on August 21, 2021 with probation release information on what the client relapsed.
Client # 5 was admitted on August 31, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on August 31, 2021 to a probation officer allowed for the release of discharge summary and aftercare plan.
Client # 7 was admitted on August 26, 2021 and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information signed and dated on August 26, 2021 to a probation officer allowed for the release of discharge summary and aftercare plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Manos House program treats clients who are adjudicated through the courts, recommended for treatment by juvenile probation, and are voluntarily participating in treatment with no legal involvement. This is a relatively new change to the client population served by Manos House.
Upon clarification by the licensing specialist, it is understood that discharge summaries may only be released to probation in cases where the client is court-committed to treatment. SOP 709.24 (a) (3) has been updated to reflect this change and the Clinical Director will ensure compliance.
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709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on one of seven client records reviewed, the facility failed to provide documentation of medication being provided as prescribed by a physician.
Client # 4 was admitted on August 4, 2021 and was still active at the time of the inspection. The client was prescribed a medication to be taken one capsule four times a day for ten days. After a review of the facility medication administration records, there was no documentation of the medication being given four times on:
August 30, 2021
August 31, 2021
September 1, 2021
September 2, 2021
September 3, 2021
September 4, 2021
September 5, 2021
September 6, 2021
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The documentation referenced above was out of compliance with DDAP regulations as well as DARS, Inc. medication documentation SOP 709.32 regarding maintaining accurate records of medication storage and dispensing.
The client referenced was prescribed a medication to take 4x per day for 10 (ten) days. Rather than document on separate medication forms designated as "Morning", "Noon", "Dinner", and "Bedtime"; the staff member initially dispensing the medication to the client recorded the medications on one form. This became difficult for subsequent staff to follow the established procedure. In addition, dates were missing on the record, which suggested that the client was not provided with the medication at the required times and doses were missed.
DARS will hold a mandatory medication procedure training for all employees on Monday, October 11, 2021 to re-train all staff on how to follow the medication procedure. Safe and secure medication storage and dispensing is crucial to the safety and quality of treatment that are the highest priorities of the DARS corporation.
During the weekly medication inventory, the Medical Supervisor will review all medication logs to ensure that prescribed medication doses are not missed. If a missed dose or documentation error is discovered, the Medical Supervisor will notify the supervisor of the shift where the error occurred. Staff found in violation of the medication dispensing will be subject to refresher trainings, and possible disciplinary action up to and including termination. |