INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 29, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Gratitude 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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704.6(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and six personnel records, the facility failed to document the completion of one clinical supervisor's completion of a core curriculum in clinical supervision.
Employee #3 was hired as a clinical supervisor on June 28, 2020 and was still in the position as of the date of the inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor attended clinical supervisor training August 23-27. Executive Director will monitor training complaince monthly and ensure all staff receive their required training hours on time. Exective Director reviewed all training requirements during staff meeting on 10/04/2021. Executive Director and Supervisors will ensure all training requirements are being met. |
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.
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Observations
Based on a review of six personnel records, the facility failed to develop a written individual training plan for each employee, appropriate to that employee ' s skill level in one record reviewed.
Employee #5 was hired on February 8, 2021 and was current at the time of the inspection. Employee #5 ' s individual training plan was not developed until June 10, 2021. Licensing Alert 03-05 identifies a time period of thirty days to develop a new hires individual training plan.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director, Clinical Supervisor, and BHT Supervisor met on August 10, 2021 to review policiies for new hire training plans. Reviewed timeline for completion within first 30 days of hire. Executive Director will review all new hire paperwork within 30 days of hire for accuracy.
Executive Director, Clinical Supervisor and BHT Supervisor will review within first 30 days of hire to ensure accuracy and ongoing complaince. |
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.
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Observations
Based on a review of the July 2020 through June 2021 fire drill logs, the facility failed to conduct an unannounced drill during the month of June 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director reviewed regulations with Maintenance Supervisor on August 09, 2021. Reviewed that pull stations need to be utilized for monthly fire drills. Maintenance will be holding a meeting on August 12 to review process and conduct a fire drill training with maintenance staff.
Executive Director and Maintenance Supervisor will ensure monthly that unannounced drills are complate and accurate. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the July 2020 through June 2021 fire drill logs, the facility failed to maintain a written fire drill record including the number of persons in the facility at the time of the drill on the fire drill log for July 2020.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Maintenance Supervisor met on August 9, 2021 to review fire drill guidelines. Maintenance will utilize the online reporting system each month, which specificially addressed number of clients and staff present during drill. Executive Director and Maintenance Supervisor will ensure form is complete and accurate each month. |
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 a review of the July 2020 through June 2021 fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
According to schedules provided by the facility, sleeping hours are considered 11:00 P.M. to 5:00 A.M. There was no documentation of a fire drill being conducted during those hours.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Maintenance Supervisor review fire drill regulations on August 9, 2021. Discussed sleep hour drills- reviewed specific hours to be completed. Maintenance supervisor will review quarterly to ensure a fire drill is conducted during sleep hours.
Executive Diretor and Manintenance Supervisor will review completed fire drills logs monthly to ensure ongoing complaince. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the July 2020 through June 2021 fire drill logs the facility failed to prepare alternate exit routes to be used during fire drills. All documented fire drills utilized the same exit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Maintenance Supervisor met on August 9, 2021 to review fire drill guidelines. Maintenance will utilize the online reporting system each month, which specifically addresses exit routs utilized during fire drill. ED reviewed fire drill regulation of utilizing alternatinge exits each month, during staff meeting on August 10, 2021. Executive Director and Maintenance Supervisor will ensure form is complete and accurate monthly. |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records and policy and procedure manual the facility failed to document written acknowledgement by clients that they have been notified that the project may not discriminate in the provision of services on the basis religion or creed.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The policy and procedures manual was updated on 7/29/2021 by the Policy and procedure committee to include religion, creed instead of the previously stated religious creed. The new policy was made available to staff on that date via the Pyramid Healthcare intranet. The compliance officer, via email, informed all programs of the change on that date and all handbooks and consents for treatment were amended to reflect the change. |
709.30 (4) 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.
(4) Clients have the right to appeal a decision limiting access to their records to the director.
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Observations
Based on a review of client records, the facility failed to include within their client rights policy that clients have the right to appeal a decision limiting access to their records to the director.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
The PHC compliance officer amended the consent to treatment in the electronic health record, to include the client's right to appeal the decision limiting access to their records. The PHC compliance officer completed this change on 9/1/2021. |
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.
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Observations
Based on a review of seven client records, the facility failed to ensure that client records contained follow up information in all four applicable records reviewed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with administrative assistant and clinical staff on August 10, 2021 to discuss follow up calls. Addressed all calls needing to made and documented within 7 days of discharge date. Clincial Supervisor will review compliance during monthly discharge chart audits.
Records quality management and clinical supervisor will monitor monthly to ensure ongoing compliance. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to ensure that a complete client record on an individual included information relative to the client's involvement with the project. There was not verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan in all seven records reviewed.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor reviewed utilization of work therapy in individual treatment plans at clinical team meeting on August 10, 2021. Clinical supervisor will review during monthly chart audits. Clinical supervisor will address any ongoing issues with clinicians during invidiual supervision.
Quality management team will continue to conduct monthly charts audits to ensure ongoing complaince. |