INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 17-18, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Auberle 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(a)(2) LICENSURE Overall Training plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of the staff development program, the facility failed to develop an overall plan for addressing staff training needs.
There was no overall training plan documented for 2023-2024.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
All future overall plans will be completed. Overall plans will be completed on a yearly basis. The Facility Director will be responsible for ensuring all individual training plans are complete and developing an overall training plan by July 30th of each fiscal year. |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
Facility has been open since April 18, 2023. Fire drill logs were submitted for July 2023, August 2023, and September 2023. No documentation provided for April, May, and June 2023.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
All fire drills will be conducted moving forward. The Program Manager will ensure monitor the logs to ensure monthly fire drills are being conducted. |
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.
|
Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one of seven records
Client #3 was admitted on August 7, 2023, and was still active at the time of the inspection. There was a Goodwill voucher referral dated September 12, 2023, which disclosed the client ' s presence in treatment. There was no release of information form for Goodwill in client #3 ' s record.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
All staff will review confidentiality policies and procedures. This will be documented in the staffs' training file. The Facility Director will audit random client charts on a weekly basis to ensure that all documentation, including releases of information, are entered correctly. Any issues will be addressed with staff during supervision. All current and future clients will be compliant and have a signed release of information prior to any disclosure of information. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
|
Observations
Based on a review of administrative information, the facility failed to inspect storage areas quarterly as required. Approval to begin services was given April 18, 2023. The inspection of storage areas was not documented for the time frame from approval to the inspection.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
Moving forward a nurse and/or trained staff will inspect the cart on a quarterly basis. Policies will be updated to reflect this. The Facility Director will review the logs to ensure that this is completed on a quarterly basis. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment in one of two applicable records.
Client #2 was admitted on July 28, 2023, and discharged due to behavior on December 27, 2023. There was no termination notice in Client #2 ' s record.
This finding was reviewed with the facility staff during the licensing process.
|
Plan of Correction
The process of any involuntary discharge will be reviewed with all staff. They will sign off acknowledging this process has been reviewed and this will be documented in their employee record. The form used will be available in both physical (paper) form and electronic through the Carelogic system (EHR). The Clinical Supervisor will review the charts on a weekly basis to ensure this is complete. |
709.34 (c) (5) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(5) Outbreak of a contagious disease requiring CDC notification.
|
Observations
Based on a review of administrative information, the facility failed to report an outbreak of a contagious disease requiring CDC notification.
There was documentation of incident reports on December 28, 2023, January 1, 2024, January 3, 2024, and January 6, 2024, for positive COVID tests that were not reported.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Effective 2/2/2024 all of these past incidents were reported in one report. Moving forward, Facility Directory will ensure all reports sent to DHS and CCBH will also be sent to DDAP and will be logged in the report binder. |
709.51(b)(1) LICENSURE Disclosure to client
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(1) Disclosure to the client of criteria for admission, treatment, completion and discharge.
|
Observations
Based on a review of client records, the facility failed to document disclosure of criteria for admission to the clients during intake procedures in seven of seven records.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The criteria for admission will be added to the client handbook and in the consent to treatment (in the clients' EHR). The clients will continue to sign off on receiving and having the handbook gone over with them, and also having the consent to treatment reviewed with them. Both of these signatures will be present in the clients' EHR. All current and future clients will be compliant. The Facility Director will monitor charts on a weekly basis to ensure this is completed. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(iii) Fee schedule.
|
Observations
Based on a review of client records, the facility failed to document familiarization of the fee schedule to the clients during intake procedures in seven of seven records.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The fee schedule will be added to the client handbook and in the consent to treatment (in the clients' EHR). The client will continue to sign off on receiving and having the handbook gone over with them, and also having the consent to treatment reviewed with them. Both of these signatures will be present in the clients' EHR. All current and future clients will be compliant. The Facility Director will review charts on a weekly basis to ensure this is corrected. |
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 include follow-up information in three of four records.
Facility policy states case managers will make follow-up calls to the client at the following intervals after discharge: 7 days, 30 days, 60 days, and 90 days, and will document all information in the client ' s record.
Client #1 was admitted on June 26, 2023, and discharged on August 11, 2023. The client record included follow-up documentation at 7, 30, and 60 days. The 90-day follow-up would have been due August 11, 2023. There was no 90-day follow-up attempt documented in client #1 ' s record.
Client #4 was admitted on August 21, 2023, and discharged on November 13, 2023. There were no follow-up attempts documented in client #4 ' s record.
Client #5 was admitted on July 28, 2023, and discharged on October 03, 2023. There were no follow-up attempts documented in client #5 ' s record.
These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The policy will be updated to include the types of discharge. Moving forward, the facility will reach out to all clients regardless of their discharge type on day 7, 30, 60, and 90 from their discharge. Staff will be trained on the updated policy and will sign off. The sign off will be documented in the employee's file. The Facility Director will monitor the employee's file to ensure this. The Facility Director will also review client's charts on a weekly basis to ensure the follow up is being completed. |