INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 16, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Salvation Army Harbor Light Center 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 fire drill logs, the facility failed to document a fire drill during sleeping hours at least every 6 months.
The fire drill logs were reviewed for the period of March 2019 to February 2021. An overnight fire drill was to be conducted in April 2020. There was no overnight fire drill documented.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will ensure the fire drills are conducted on overnight shifts at minumum, every six (6) months and are placed as a reminder a drill is due on the Director's Outlook calendar at the start of that month.
When a drill is due during overnight hours, the Director will assign a Recovery Support Specialist to conduct the fire drill and offer options for the route of evacuation for that drill to make sure that all exits are utilized on a routine basis, and a offer a "due by" day and a timeframe during overnight hours the drill is to be conducted. The Recovery Support Specialist on shift at the time will determine in the time window, when to conduct the drill.
The Lead Recovery Support Specialist will conduct monthly supervision with the overnight Recovery Support Specialist to remind them that a fire drill needs to be conducted at some time during their shift that month, the drill it is to be conducted prior to 4am, and suggested routes to be utilized. This will be recorded on a fire drill log, signed by all individuals present at the time of the drill, and submitted to the Director for review and signature.
This POC is in effect beginning 4/1/2021 and will be monitored at minimum every six (6) months by the Director of the program. |
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 the review of client records, the facility failed to obtain and informed and voluntary consent in one of seven client records.
Client # 1 was admitted on December 22, 2020 and was still an active client at the time of the inspection. A letter was sent to an organization on December 23, 2020. There was no release documented. A letter was sent to an individual on March 1, 2021. There was no release documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All clinical staff who need Confidentiality training will be scheduled within the next 3 months to take the training. The Director and Clinical Supervisor will monitor all outgoing correspondence to ensure no information is being released without proper release of information. The Director will sign off on any letters or correspondence to outside providers, individuals, or agencies after review of all ROI have been completed.
The Director will also inform the Intake Case Manager of the standard ROI's needed, provide that individual with a list of said standard ROI's, and make sure that they are all contained in an intake packet so they are able to be completed at intake.
The Clinical Supervisor, while completing monthly chart audits, will ensure all ROI's are up to date and contain all of the necessary information.
All Counselors, Counselor Assistants, Therapists will present any written letters or documentation and the valid ROI to the Director for approval and signatures on the letter.
This POC is effective 4/1/2021 and will be monitored daily by the Director and Clinical Supervisor. |
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 the review of client records, the facility failed to document a consent that identified the specific information to be disclosed in one of seven client records.
Client # 7 was admitted on May 8, 2020 and discharged on June 28, 2020. A release of information was documented for a third-party payer. Specific information to be disclosed exceeded the parameters of 4 Pa. Code 255.5. Information was sent to the third-party payer on May 16, 2020 and the information sent exceeded the parameters of 4 Pa. Code 255.5.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All clinical and administrative staff have been given a copy of the parameters of 4 Pa. Code 255.5 and instructed to never release information outside of those parameters.
The Director will ensure all staff needing Confidentiality training will enroll within the next three (3) months. The Director and Clinical Supervisor will also monitor release of information via supervisions, review of all outgoing correspondence before it is sent, signing off on that outgoing correspondence if it meets 4 Pa. Code 255.5, and having conversations regarding what can be released.
The Director and Clinical Supervisor will be responsible for monitoring all outgoing correspondence to ensure it complies with 4 Pa. Code 255.5, returning it to the proper staff member for revisions if it does not, then signing off on the correspondence before it is sent to maintain confidentiality.
This POC is effective 4/1/2021 and will be monitored by the Director and Clinical Supervisor. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement the client was notified of the right that, no client may be deprived of a civil right solely by reason of treatment in seven of seven client records.
Client records # 1, 2, 3, 4, 5, 6 and 7 were missing documentation they were notified of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/16/2021 the Director has updated the acknowledgement the client was notified of the right that no client may be deprived of a civil right solely by reason of treatment in accordance with licensing standards.
This updated notification has been distributed to all existing clients at the facility, has been updated in the Policy and Procedure manual, and has been updated in the client handbook.
The Director will maintain updated on the changes to any policy changes through licensing and update any policies accordingly. The Director has made sure the updated policy was distributed and placed in the appropriate handbook/manuals. This POC was effective 3/16/2021. |
709.30 (3) LICENSURE Client rights
709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(3) Clients have the right to inspect their own records. The project, facility or clinical director may temporarily remove portions of the records prior to the inspection by the client if the director determines that the information may be detrimental if presented to the client. Reasons for removing sections shall be documented in the record.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement the client was notified of the right that, reasons for removing sections of the record shall be documented in the record, in seven of seven client records.
Client records # 1, 2, 3, 4, 5, 6 and 7 were missing documentation they were notified of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/16/2021 the Director has updated the policy notifying clients of the right regarding removing sections of the record will be documented in the record. All existing clients at the facility have received an updated copy of this policy and the Director was available in a group setting to answer any questions those clients may have about removal of sections and the documentation of such. The Director has also placed an updated policy in the Policy and Procedure manual and the client handbook.
The Director will be responsible for remaining up to date on licensing policy and procedure, making appropriate changes when necessary, and updating clients as needed. The Director is also responsible for insuring all staff are aware of updated policy and procedures and obtaining signatures that staff has been updated. This POC is effective 3/17/2021. |
709.30 (5) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(5) Clients have the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement the client was notified of the right that, the client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records in seven of seven client records.
Client records # 1, 2, 3, 4, 5, 6 and 7 were missing documentation they were notified of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/16/2021 the Director has updated the policy to include acknowledgement the client was notified of the right that, the client has the right to request the correction of inaccurate, irrelevant, outdated or incomplete information in their records. This updated policy has been given to all existing clients at the facility and has been added to the Policy and Procedure manual and the client handbook. As of 3/17/2021 all new clients entering the program will receive this updated policy as part of their client handbook.
The Director will remain up to date on changes to licensing policy and make the appropriate changes accordingly and without hesitation. This POC is effective 3/17/2021. |
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.
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Observations
Based on the review of client records, the facility failed to document the client was notified, in writing, of the decision to involuntarily terminate the client in one of one client record.
Client # 7 was admitted on May 8, 2020 and involuntarily terminated on June 26, 2020. There was no documentation the client was notified in writing.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the annual licensing inspections conducted on February 19, 2019, May 11, 2018, and April 18, 2017.
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Plan of Correction
As of 3/17/2021 the Director has met with Clinical Staff to remind them that a discharge letter needs to be completed for ALL discharges, including involuntary, with an appropriate reason for discharge listed on the letter.
A client who is involuntarily terminated from the program will have a conversation with their assigned counselor and Clinical Supervisor to make them aware of the reason for termination. This will then be documented in the Continuing Care Plan, Discharge Summary, Discharge note, and discharge letter. The client will receive a copy of the continuing care plan and the discharge letter. The client will sign the Continuing Care Plan and the Discharge Summary both indicating an understanding of the reason(s) for discharge. The Counselor will sign the documentation as well and the Director is an additional signature on the Continuing Care Plan.
All clinical staff were sent, by the Director, a template for the discharge letter to insure continuity across discharges. All clinical staff are instructed to give a copy of the signed and dated letter to the client upon their leaving, regardless of the reason for discharge.
If the client leaves before the discharge letter can be completed, the clinical staff have been instructed to send the letter to the address listed on file, document in the discharge note that it was sent, and a copy of the letter (including the date it was sent) will be placed in the discharge packet of the client's chart.
If no address is listed, a sealed letter will be given to a case manager, probation officer, etc, as long as a consent exists, for transport to the client and will be documented in a discharge note along with who took the letter, date, and time. A client has the right to refuse acceptance of the discharge letter and if that happens the counselor will document in the discharge note the client refused a copy, but an original will be placed in the discharge section of each chart.
The Director and Clinical Supervisor are responsible for ensuring this documentation occurs. This POC is effective 3/17/2021. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to document the client was notified of the opportunity to request reconsideration of the decision terminating treatment., in one of one client record.
Client # 7 was admitted on May 8, 2020 and involuntarily terminated on June 26, 2020. There was no documentation the client was notified of the opportunity to request reconsideration of the decision to terminate treatment.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
As of 3/17/2021 the Director has updated the policy to include the client was notified of the opportunity to request reconsideration of the decision terminating treatment and has been added to the discharge letter. All discharge information, including documentation the client was notified of the opportunity to request reconsideration, will be documented in the discharge note.
The policy update has been added to the client handbook and the policy and procedure manual by the Director.
The Clinical Supervisor will, through closed chart audit within 7 days of discharge, ensure there is documentation that the client was notified of their opportunity to request reconsideration of termination of discharge in the client's discharge letter and via discharge note.
This POC is effective 3/25/2021. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to document a physical examination in four of seven client records.
Client record # 1 was admitted on December 22, 2020 and was still an active client at the time of the licensing inspection. There was no documentation of a physical examination.
Client record # 3 was admitted on November 5, 2020 and was still an active client at the time of the licensing inspection. There was no documentation of a physical examination.
Client record # 4 was admitted on January 28, 2020 and was still an active client at the time of the licensing inspection. There was no documentation of a physical examination.
Client record # 5 was admitted on August 18, 2020 and was still an active client at the time of the licensing inspection. There was no documentation of a physical examination.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Due to lack of insurance for a majority of clients at the facility, clients have to attend Medical appointments a a facility which accepts clients without insurance coverage or low income.
As of 3/18/2021, a doctor assessment form has been completed by the Director and will be given to all clients on the morning of their appointment.
The Director has notified the supervisor at the healthcare facility of the need for documentation of physicals and that all clients from the facility will be bringing a medical form with them when they attend. All physicals will be scheduled within 7 days of admit and clients will bring the completed form back with them from the appointment as the healthcare facility has been notified they will have it.
The Director will meet with the Intake Case Manager weekly prior to medical appointment days, or whenever their appointment is scheduled at another healthcare facility, to remind that individual all clients going need to have the medical form and those forms need to be completed in full and return with the client. They will then be collected by the Intake Case Manager and placed in the chart for filing.
If the form is lost or is not completed in full, the Intake Case Manager will contact the healthcare facility and request a new form be completed and sent back. All consents will be completed prior to attendance of these appointments.
This POC is effective as of 3/18/2021. |