INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 23, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Tradition 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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705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
It was observed by DDAP staff that the street level exit from the right fire tower, when facing the street, exited onto a sidewalk that was littered with debris that may pose a slip, trip or fall hazard during an emergency.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Maintenance removed the debris from the sidewalk entrance to the fire door on August 25, 2024. This will continue to be monitored by maintenance staff and the risk committee with monitor during monthly safety walk throughs. |
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 client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in two of two applicable client records reviewed.
The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in DDAP Licensing Alert 02-21.
Client # 5 was admitted on March 19, 2024, and was discharged against medical advice on March 27, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
Client # 7 was admitted on May 8, 2024, and was discharged against medical advice on June 13, 2024. There was no documentation that the emergency contact was notified of the clients discharge from the facility against medical advice as of the date of the inspection.
This is a repeat ciation from the June 21, 2023 licensing renewal inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor will review protocol for notifying emergency contact when a client leaves treatment against facility advice, during clinical staff meeting on September 3, 2024. Staff will also be re-educated to document in the clinical chart if they refused to sign an ROI for an emergency contact and circumstances of this. Executive Director and Clinical Supervisor will review this while completing discharge chart audits to ensure ongoing compliance. |
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to complete treatment plans, within facility policy timeframe guidelines, in five out of seven applicable client records reviewed. The facility's policy is to complete a comprehensive treatment plan within seven days of admission.
Client #1 was admitted on August 6, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than August 13, 2024; however, it was not completed until August 19, 2024.
Client #2 was admitted on June 21, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than June 28, 2024; however, it was not completed until July 3, 2024.
Client #3 was admitted on June 20, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was due no later than June 27, 2024; however, it was not completed until July 10, 2024.
Client #4 was admitted on June 20, 2024, and was discharged on July 20, 2024. A comprehensive treatment plan was due no later than June 27, 2024; however, it was not completed until July 16, 2024.
Client #7 was admitted on May 8, 2024, and was discharged on June 13, 2024. A comprehensive treatment plan was due no later than May 15, 2024; however, there was no documentation to verify a comprehensive treatment plan had been completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review comprehensive treatment plan timeframes with clinicians during clinical staffing on September 3, 2024. She will monitor compliance during monthly chart audits. Any ongoing issues with be address by clinical supervisor during monthly supervision. |
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
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in one out of three applicable client records.
Client #2 was admitted on June 21, 2024, and was still active at the time of the inspection. A comprehensive treatment plan was completed on July 3, 2024, and the update was due no later than August 3, 2024; however, the next update was completed on August 5, 2024.
This is a repeat ciation from the June 21, 2023 licensing renewal inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor reviewed guidelines for treatment plan updates with clinicians during clinical staffing on September 3, 2024. Clinical Supervisor will monitor ongoing compliance/maintianing time frames for completion during monthly chart audits. Any ongoing issues will be address by clinical supervisor during monthly supervision. |
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
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of six applicable records reviewed.
Client #2 was admitted on June 21, 2024, and was still active at the time of the inspection. The comprehensive treatment plan dated July 3, 2024, indicated the client would receive two individual therapy session per month. During the month of July 2024, only one individual session was documented in the client record.
Client #3 was admitted on June 20, 2024, and was still active at the time of the inspection. The comprehensive treatment plan dated July 10, 2024, indicated the client would receive two individual therapy sessions per month. During the month of July 2024, there was no documentation in the client record to verify that they had received any individual sessions.
Client #6 was admitted on June 7, 2024, and discharged on June 30, 2024. The comprehensive treatment plan dated June 14, 2024, indicated the client would receive group therapy once a week. There was no documentation in the client record to verify that they had received group therapy during the weeks of June 16-22, 2024, and June 23-29, 2024.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Supervisor will review regulations for completion of individual therapy sessions during clinical meeting on September 3, 2024. Executive Director and Clinical Supervisor will monitor ongoing compliance during monthly chart audits. Clinical Supervisor will monitor clinicians schedules to ensure clients are scheduled and appointments are kept per regulations. Any ongoing issues with be address individually in clinical supervision. |
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 a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of four applicable discharged records reviewed. The facility's policy is to follow-up with discharged clients within seven days of discharge.
Client #4 was admitted on June 20, 2024, and was discharged on July 20, 2024. A follow-up contact was to be completed no later than July 27, 2024; however, there was no documentation in the client record that it had been completed.
Client #5 was admitted on March 19, 2024, and was discharged on March 27, 2024. A follow-up contact was to be completed no later than April 3, 2024; however, the follow-up contact was not completed until April 8, 2024.
This is a repeat ciation from the June 21, 2023 licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed follow up policy with administrative assistant/staff on August 28,2024. Discussed documenting within seven days of discharge. Discussed documenting if there was no forwarding information for the client, if they were unable to be reached etc. Executive Director and Clinical Supervisor will review compliance during monthly chart audits. Any additional concerns will be addressed in monthly supervision with the Executive Director. |