INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 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, Peace and Harmony 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's August 2023 through March 2024 fire drill logs, the facility failed to conduct unannounced fire drills, at least once a month, during the months of October 2023, December 2023, and February 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately Facility Director will make sure each month there are unannounced fire drills conducted in the facility. Compliance Officer will audit the logs by the 25th of the month to make sure that the unannounced fire drills have taken place and it is documented correctly in the log. |
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 a review of client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in three of seven client records reviewed.
Client #1 was admitted on October 2, 2023 and was active at the time of inspection. There was documentation of disclosures to a urinalysis laboratory on November 16, 2023, November 24, 2023, November 30, 2023, and December 8, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #2 was admitted on October 4, 2023 and was active at the time of inspection. There was documentation of disclosures to a urinalysis laboratory on December 3, 2023, December 9, 2023, and December 19, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
Client #4 was admitted on September 8, 2023 and was discharged on November 22, 2023. There was documentation of a disclosure to a urinalysis laboratory on November 7, 2023; however, there was no consent to release information form signed by the client documented in the record prior to the disclosures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Executive Assistant created a consent for disclosure for the urinalysis laboratory. Clinical Supervisor and Executive Asst. reviewed the intake packet and made sure all documents/consents needed are in the intake packet. Clinical Supervisor/Lead Counselor will check all intake packets upon completion to make sure all consents have been signed. Counselors have had all active clients sign consents for the urinalysis laboratory. |
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).
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Observations
Based on a review of client records, the facility failed to document the dated signature of client on a release of information form in one of seven client records reviewed.
Client #6 was admitted on September 11, 2023 and was discharged on February 22, 2024. There was a release of information form to the funding source that was signed and dated by facility staff on October 2, 2023; however, the dated signature of the client was not included on the form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately Clinical Supervisor/Lead Counselor will check all intake packets upon completion to make sure all consents have been signed. If there is a consent missing a signature facility will not disclose any information and during the next session client will sign the consent. |
709.93(a)(11) LICENSURE Client records
709.93. 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 maintain a complete client record, which is to include the documentation of follow-up information, in one of two applicable client records reviewed.
Client #7 was admitted September 29, 2023 and was discharged on January 3, 2024. There was no documentation of follow-up in the record at the time of inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately Clinical Supervisor/Lead Counselor will complete random chart audits to make sure all client have complete client records within them. Clinical Supervisor/Lead Counselor will audit the discharge chart within 7 business days to make sure all client records are in there and that they have received the follow up documentation for client records. |