INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 24, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Angels Light Half Way House, LLC 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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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on the review of the facility's fire drill log for the months of May 2023 through March 2024, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. There was only one overnight fire drill documented on December 21, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drills will be held a minimum of once a month. The Office Manager has agreed to take responsibility for conducting and documenting the fire drills until the time the facility became operational and fully staffed. At that time, the Office manager will be responsible for overseeing that a support staff (techs) person from all three shifts, conduct a minimum of one fire drill per month and documenting it in the fire drill log. Fire drills will be conducted at various times during the day and night. Starting 5/1/2024, the office manager will schedule the rest of the calendar years fire drills on the calendar to ensure that overnight fire drills are conducted every six months, with the next one scheduled on September 22, 2024 at 11:10pm. |
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 a review of client records, the facility failed to provide documentation of a complete medication administration record (MAR) in four of seven applicable records.
Client #1 was admitted on February 26, 2024 and was still an active client. Starting at admission, a medication was to be given "take 1 tablet by mouth at bedtime." There was no documentation of this medication given on February 28, 2024, March 21, 2024, and March 30, 2024.
Client #4 was admitted on February 12, 2024 and discharged on March 1, 2024. Starting at admission, a medication was to be given "take 1 tablet twice a day. " The MAR documented that the medication was given at 8:00am and 8:00 pm. There was no documentation of this medication given at 8:00pm on February 17, 2024.
Starting at admission, a medication was to be given "take 1 capsule twice a day. " The MAR documented that the medication was given at 8:00am and 4:00 pm. There was no documentation of this medication given at 4:00pm on February 15, 2024.Starting at admission, a medication was to be given "take 2 tablets twice a day." The MAR documented that the medication was given at 8:00am and 4:00 pm. There was no documentation of this medication given at 8:00am on February 20-23, 2024 and February 26-29, 2024. There was no documentation of this medication given at 4:00pm on February 15-16, 2024.
Client #5 was admitted on February 22, 2024 and discharged on March 12, 2024. Starting at admission, a medication was to be given "take 1 tablet at bedtime. " There was no documentation of this medication given on March 7, 2024.Starting at admission, a medication was to be given "take 1 tablet at bedtime. " There was no documentation of this medication given March 1-10, 2024.
Client #7 was admitted on February 28, 2024 and discharged on April 16, 2024. Starting at admission, a medication was to be given "take 1 tablet twice a day. " There was no documentation of this medication given on March 24-25, 2024 and March 31, 2024.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the January 10, 2024 licensing inspection.
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Plan of Correction
In their first meeting with their counselor, five days from admission, members are scheduled for all medication refills with Independence Health Systems, MAT programs, or mental health providers to ensure that members do not run out of their medication after their 30-day prescription that was sent from their referring agency.
Hayden's Pharmacy is called the day of arrival to ensure that all the members medications were sent (30-days), if they did not come with them or have a paper prescription.
As per DDAP regulation 709.32, if a client runs out of medication, the counselor will write a general note in the client's chart to what actions were addressed to not have a disruption in their medications. The facility director will be notified, and the proper actions will be taken.
Hayden's Pharmacy was notified and spoke with Ed, the owner and pharmacist, to ensure that medication refills are delivered the same day the refill was called in to not have a distribution in member medications.
As per regulation 709.53(a)(2), clients who refuse their medication will be documented on the back of the MARS sheet of why the medication was refused. The lead tech will inform the clinician of why the client refused their medication so they can write a general note in the client's chart. When a client is out of medication, the clinician will write a general note of the plan of correction as to what has been done to fix the medication issue.
Medication observation training for all support staff was conducted on 5/2/2024 where all support staff who observe medication pass were present. The inhouse training will be conducted by the lead tech and clinical supervisor.
A DDAP medication training will be scheduled when training is available (email was sent on 4/29/2024 to enquire about the next scheduled training but have yet to get a response). On this same day, all support staff who dispense medications will initial the MARS book along with the pill package when medications are observed during medication pass.
ALHH has also implemented on 4/25/2024, a counselor to client medication follow-up paper that is filled out asking the following: the reason for client follow-up and the outcome of the follow-up call regarding medications that will be placed in a binder to ensure that all medications are handled in a timely manner. On this same day, the lead support staff will conduct daily inventory of medications and when there is four days left of a medication, the refill will be called into the pharmacy to ensure that all medications are here in a timely manner. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on applicable client records reviewed, the facility failed to provide a discharge summary in accordance with the facility policy and procedure manual in two of four records. The policy and procedure manual indicates a discharge summary be completed within twenty-four hours of discharge.
Client #4 was admitted on February 12, 2024 and was discharged on March 1, 2024. The discharge summary was due to be completed no later than March 2, 2024; however it was not completed until March 5, 2024
Client #5 was admitted on February 22, 2024 and was discharged on March 12, 2024. The discharge summary was due to be completed no later than March 13, 2024; however, it was not 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
Corrective Action: Angel's Light Clinical Supervisor conducted a 60-minute training 4-25-2024 with all the counselors reviewing treatment planning and discharge documentation in the electronic records. The training discussed the importance of the discharge process and documentation. Clinical Supervisor will monitor treatment plans weekly ensuring documentation of the discharge summary is completed within seven days of discharge to be compliant with 709.53 regulations. |
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.
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Observations
Based on applicable client records reviewed, the facility failed to provide follow-up contact in accordance with the facility policy and procedure manual in three of three applicable records reviewed. The policy and procedure manual indicates follow-up contact must be made within five days of discharge.
Client #4 was admitted on February 12, 2024 and was discharged on March 1, 2024. There was no documentation of follow-up being completed.
Client #5 was admitted on February 22, 2024 and was discharged on March 12, 2024. There was no documentation of follow-up being completed.
Client #6 was admitted on February 26, 2024 and was discharged on April 1, 2024. There was no documentation of follow-up being completed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The counselors have been made aware to conduct a 30-day follow up call to patients regardless of discharge status. The verified call will be documented in the patient file. The clinical supervisor will monitor and verify follow up calls are being conducted and documented.
Starting 5/2/2024, the clinical supervisor will keep a binder of discharged clients and write down the day of discharge and when their follow-up call will be made to ensure that all follow-up calls are made 30-days from the discharge date. The follow-up binder will be viewed every day and calls will be made the day they are due. All client follow-ups will be documented on the client follow-up discharge paper and then scanned into their EMR. |