INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 16, 2017 through February 17, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, ADAPPT House, 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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709.28 (b) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(b) The project shall secure hard copy client records within locked storage containers. Electronic records must be stored on secure, password protected data bases.
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Observations
Based on the physical plant inspection conducted on February 17, 2017, it was discovered that the facility failed to secured patient records in locked storage containers. One client record was found on the desk in an unlocked and unattended counselor's office.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with all counseling staff regarding client confidentiality. Counseling staff were reminded that unattended offices were to be locked at all times, and at no time shall opened client files be left unattended on a counselor's desk.
The Clinical Supervisor shall make periodic checks of counselor's offices to ensure this procedure/protocol is being adhered to. |
705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
Based on a physical plant inspection conducted on 2/17/16 between 9:00 am and 10:15 am, it was observed that the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety as evidenced by the following:
1)Cracked, chipped, broken and loose tiles were found in the first floor lavatory behind the security desk.
2)Wooden ceiling support structure showed signs of decomposition and structure weakness in the area of the drop ceiling to the left of the common area kitchen.
3)Common area kitchen sink area counter tops were buckling, warped and showed noticible signs of cracking.
4)Floor below the common area kitchen was warped and buckling. Tiles were pulling away from subfloor.
5)Pantry area of kitchen, on the floor, to the right of the door jam, had broken tiles and the floor noticeably sank when stepped on.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
1. Cracked, chipped, broken, and loose tiles found in the lavatory behind the Security Desk have been replaced by maintenance personnel.
Physical plant inspections of the facility shall take place on a daily basis, at which time any and all necessary repairs shall be addressed as soon as possible.
2. The wooden ceiling support structure to the left of the common kitchen area has been re-finished, and no longer shows signs of decomposition.
Maintenance staff shall make periodic inspections to ensure there are no signs of decomposition.
3. The common area kitchen sink area counter tops shall be replaced by maintenance personnel within 60 days.
4. Flooring shall be replaced by maintenance staff on the floor below the common area kitchen and completed within 60 days.
5. Contractor bids shall be sought to repair the broken tiles and an area of the kitchen floor in the Pantry area of the kitchen and completed within 60 days. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection on February 17, 2017 at approximately 9 A.M. to 10:15 A.M., the facility failed to ensure that all heaters in the facility were permanently mounted or installed.
The office located in the kitchen to the right of the main entrance door had a space heater located on top of the desk.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A space heater found in the kitchen has been permanently removed. All staff has been made aware that facility heaters are not permitted unless permanently mounted or installed.
The Food Service Manager shall ensure that at no time will facility heaters be allowed unless permanently mounted or installed. |
709.53(a) LICENSURE Complete Client Record
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:
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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 progress notes, discharge summaries, follow up information, and aftercare plans, in client records #1, 2, 3, 4, 5, 6 and 7.
Client #1 was admitted on 12/19/16 and was an active client at the time of inspection. The client record did not contain a progress note matching the record of service for the week of 1/1/17-1/7/17.
Client #2 was admitted on 12/22/16 and was an active patient at the time of inspection. The client record did not contain any documentation of a progress note matching the record of service for the week of 1/7/17 as of the date of the inspection.
Client #3 was admitted on 12/19/16 and was an active patient at the time of inspection. The client record did not contain any documentation of a progress note matching the record of service for the weeks of 1/2/17, 1/3/17-1/27/17, and 1/27/17-2/14/17 as of the date of the inspection.
Client #4 was admitted on 7/11/16 and was discharged on 9/12/16. The client record did not contain any documentation of follow-up information or discharge summary as of the date of the inspection.
Client #5 was admitted on 5/16/16 and was discharged on 7/18/16. The client record did not contain any documentation of an aftercare plan as of the date of the inspection.
Client #6 was admitted on 2/10/16 and was discharged on 3/10/16. The client record did not contain any documentation of a progress note matching the record of service for the weeks of 2/24/16 and 3/1/16. Additionally, the client record did not contain documentation of follow up as of the date of the inspection.
Client #7 was admitted on 8/15/16 and was discharged on 10/14/16. The client record did not contain any documentation of a progress note matching the record of service for the weeks of 10/5/16 and 10/12/16. Additionally, the client record did not contain any documentation of follow-up information or a discharge summary as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Albeit late, all necessary documentation has been completed and placed in the "active" charts. A note has been placed in the "discharged" charts indicating "missing documents" due to unexpected counselor resignations/separations. The Clinical Supervisor has met with all clinical staff and presented the protocol to staff to follow regarding client charts. A sign-in sheet for individual sessions shall to turned in within 24 hours after the session, and the service log is to maintained /updated on a daily basis and kept in the client's chart. At no time shall the "Record of Service" be removed from the chart. The Clinical Supervisor shall do weekly checks to ensure that this mandatory protocol/procedure is followed. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of staff records the facility failed to conduct a written semiannual performance evaluation for employee #6 who is a Counselor Assistant and still employed at the facility. This evaluation was due no later than 9/14/16 and was not completed at the time of inspection.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
Although late, a written "semi-annual" evaluation has been placed in the Counselor Assistants' personnel file.
The Facility Director shall ensure that 6 month written semi-annual performance evaluations are timely and based on measurable performance standards, and shall be located in the Counselor Assistant's personnel. |