INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on February 14, 2022 through February 15, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Adappt 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:
|
Plan of Correction
|
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
|
Observations
Based on a review of personnel records, the facility failed to provide documentation of an individual training plan, which is to be developed with input from both the employee and the supervisor, in one of eight personnel records reviewed. Employee #2 was hired as the facility director on July 2, 2021. The individual training plan was signed by the employee on February 14, 2022 but was not signed by the supervisor.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director has had her individual training plan signed by her Supervisor on February 23, 2022. Facility Director will ensure that all training records/training plans will be signed. Program Manager will monitor this progress to ensure that all training plans are signed. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of the facility's Staffing Requirement Facility Report and personnel records, the facility failed to ensure that employee #9, a monitor hired on June 22, 2016, received at least 4 hours of TB/STD and other health related topics within the regulatory timeframe. There was no documentation of the completed TB/STD training in the personnel file at the time of inspection.This finding was discussed with facility staff during the licensing process.
|
Plan of Correction
By 5/1/22, employee #9 and all other staff will have completed at least 4 hours of TB/STD and other health related trainings. Moving Forward all new employees will have completed this training.
The project director will monitor the progress until this has been completed.
|
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that frozen food was kept at or below 0 degrees Fahrenheit. The freezer, located in the kitchen, registered a temperature of 10 degrees Fahrenheit.This finding was reviewed with facility staff during the licensing inspection.This is a repeat citation from the February 24, 2021 annual licensing inspection.
|
Plan of Correction
By 3/31/22, a contracted refrigeration technician will be at the facility to inspect the freezer temperature to ensure that the freezer is at OF or below. The project director will monitor the progress until this has been completed. |
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.
|
Observations
Based on a physical plant inspection, the facility failed to ensure that all facility heaters were permanently mounted or installed. There were portable space heaters found in counseling offices #3 and #4 at the time of the inspection. This finding was reviewed with facility staff during the licensing inspection.
|
Plan of Correction
On 2/16/22, the portable space heaters have been removed from offices #3 and #4. Facility Director will ensure that staff will no longer utilize portable space heaters in any areas of the facility. |
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.
|
Observations
Based on a review of the facility ' s January 2021 through January 2022 fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every six months. There were no fire drills conducted during the facility ' s 11:00pm to 6:00am overnight hours for the reviewed period.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Beginning 3/1/22, fire drills will be conducted during sleeping hours, 11:00pm-6:00am every 6 months. Facility Director will monitor this. |
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.
|
Observations
Based on a review of the facility's policy manual, the facility failed to document written procedures for the management of treatment/rehabilitation services for clients. There was no documentation of a policy and procedure regarding the requirement that inpatient rehabilitation facilities notify a client's designated emergency contact when the client leaves treatment against medical advice.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
Facility Director has written a policy and procedure regarding the requirement that inpatient rehabilitation facilities notify a client's designated emergency contact when a client leaves treatment against medical advice. Counselors will begin to implement this policy along with a form in which clients will sign designating a n emergency contact. Counselors will begin to implement this policy effective 3/2/22. The project director will monitor the progress until this has been completed. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
|
Observations
Based on a review of client records, the facility failed to document a dated signature of the client on release of information forms in one of seven client records reviewed.Client #7 was admitted on January 6, 2022 and was active at the time of inspection. There was a release of information form to an emergency contact signed by the witness on January 6, 2022; however, the dated signature of the client was not documented on the form.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 3/15/22, Facility Director will ensure that all documents are signed and dated by the client according to 42 CFR 2.14 (a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients). Facility Director will monitor this by completing chart checks at 1 week and 30-day reviews. The project director will monitor the progress until this has been completed. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
|
Observations
Based on a review of client records, the facility failed to document a dated signature of the witness on release of information forms in one of seven client records reviewed.Client #6 was admitted on January 12, 2022 and was active at the time of inspection. There was a release of information form to an emergency contact signed by the client on January 12, 2022; however, the signature of the witness was dated January 12, 2023.This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
By 3/15/22, Facility Director will ensure that all documents are correctly signed and dated by the client and staff. Facility Director will monitor this by completing chart checks at 1 week and 30-day reviews. By March 31, 2022 Facility Director will provide a refresher training to clinical staff members regarding all client documents and the clinical documentation process. The project manager will monitor the process for 90 days or until compliance is achieved and sustained. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
|
Observations
Based on a review of client records, the facility failed to ensure that a copy of a client consent to release information form was offered to the client in two of seven client records reviewed.Client #1 was admitted on October 6, 2021 and was discharged on December 6, 2021. Release of information forms to a funding source and another treatment facility were signed and dated by the client on October 6, 2021 and neither form documented whether copies were offered to the client.Client #7 was admitted on January 6, 2022 and was active at the time of inspection. A release of information form to a physician was signed and dated by the client on January 6, 2022 and there was no documentation that a copy was offered to the client.This finding was reviewed with facility staff during the licensing inspection.This is a repeat citation from the February 24, 2021 annual licensing inspection.
|
Plan of Correction
By 3/15/22, the Facility Director will provide training to clinical staff members regarding client confidentiality, including verification that a client was offered a copy. By March 31, 2022, the facility director will provide refresher training to clinical staff members regarding weekly clinical service requirements and the clinical documentation process. Beginning March 15, 2025, the facility director will complete weekly clinical chart reviews to verify treatment services have been documented as required. The project manager will monitor the process for 90 days or until compliance is achieved and sustained. |
709.32 (c) (1) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(c) The project shall have and implement a written policy and procedures regarding all medications used by clients which shall include, but not be limited to:
(1) Administration of medication, including the documentation of the administration of medication:
(i) By individuals permitted to administer by Pennsylvania law.
(ii) When self administered by the client.
|
Observations
Based on a review of client records, the facility failed to ensure that there was proper documentation of the administration of medication in one of two applicable records reviewed.Client #1 was admitted on October 6, 2021 and was discharged on December 6, 2021. The client was prescribed medication to be administered one time a day; however, medication records were missing from November 16, 2021 through December 6, 2021. This finding was reviewed with facility staff during the licensing inspection.This is a repeat citation from the February 24, 2021 annual licensing inspection.
|
Plan of Correction
By March 15,2022, the operations director will revise the "medication control" form to include documentation of the reasons for missed doses. Beginning March 15,2022, the operations director will assign a security staff member to audit medication control forms weekly to verify that the reasons for missed medication doses have been documented. The facility director and project manager will monitor the process for 90 days or until compliance is achieved and sustained. |
709.34 (c) (4) 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:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
|
Observations
Based on a review of the unusual incident report logs, the facility failed to file a written unusual incident report with the Department within three business days following an incident requiring the on-site presence of police, fire, or ambulance personnel. There were documented incidents that occurred on the following dates that were not reported to the Department: May 8, 2021; July 15, 2021; July 19, 2021; August 5, 2021; August 26, 2021; September 6, 2021; September 17, 2021; September 27, 2021; October 3, 2021; October 23, 2021; October 26, 2021; October 27, 2021; November 1, 2021; December 6, 2021; and December 14, 2021.This finding was reviewed with facility staff during the licensing inspection.This is a repeat citation from the February 24, 2021 annual licensing inspection.
|
Plan of Correction
On 2/16/22, facility director entered all unusual incident reports to the Department. Facility director will continue to send all unusual incident reports through the DDAP portal. |
709.53(a)(5) LICENSURE Progress Notes
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:
(5) Progress notes.
|
Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include progress notes, in six of seven client records reviewed.Client #1 was admitted on October 6, 2021 and was discharged on December 6, 2021. There were entries in the record of service; however the record did not contain documentation of group notes for October 7, 2021 and October 8, 2021. Additionally, the record did not contain documentation of individual session notes for the week of November 14, 2021 through November 20, 2021.Client #2 was admitted September 1, 2021 and was discharged on November 1, 2021. There were entries in the record of service; however, the record did not contain documentation of group notes for the entire month of September 2021 and for the weeks of October 3, 2021 through October 16, 2021.Client #3 was admitted October 17, 2021 and was discharged on December 17, 2021. There were entries in the record of service; however, the record did not contain documentation of group notes for December 6, 2021 through December 9, 2021 and December 16, 2021.Client #4 was admitted on September 20, 2021 and was discharged November 19, 2021. There were entries in the record of service; however, the record did not contain documentation of group notes for the entire month of October 2021, except for October 1, 2021. Client #5 was admitted on December 22, 2021 and was active at the time of inspection. There were entries in the record of service; however, the record did not contain any group notes after January 10, 2022.Client #7 was admitted on January 6, 2022 and was active at the time of inspection. There were entries in the record of service; however, the record did not contain documentation of any group notes since admission. Additionally, the record did not contain documentation of individual session notes for the weeks of January 23, 2022 through January 29, 2022, January 30, 2022 through February 5, 2022, and February 6, 2022 through February 12, 2022.This finding was discussed with facility staff during the licensing process.
|
Plan of Correction
By March 15,2022, the facility director will provide refresher training to clinical staff members regarding weekly clinical service requirements and the clinical documentation process. Beginning March 15, the facility director will do weekly clinical chart reviews to verify treatment services have been documented as required. The project manager will monitor the progress for 90 days or until compliance is achieved and sustained. |
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 a maintain a complete client record on an individual, which is to include follow-up information, in two of four applicable client records reviewed.Client #1 was admitted on October 6, 2021 and was discharged on December 6, 2021. There was no documentation of follow up information as of the date of the inspection. Client #2 was admitted on September 1, 2021 and was discharged on November 1, 2021. There was no documentation of follow up information as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
By March 15, 2022, the facility director will provide refresher training to clinical staff members regarding weekly clinical service requirements and the clinical documentation process. Beginning March 15,2022, the facility director will complete weekly clinical reviews to verify that client follow-ups be done within one week of discharge. The project manager will monitor the progress for 90 days or until compliance is achieved and sustained. |