INITIAL COMMENTS
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This report is a result of an on-site complaint investigation conducted on March 10-11, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention & Treatment. Based on the findings of the on-site inspection, The Highland House, Inc., was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this investigation.
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Plan of Correction
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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
The facility failed to ensure that the facility was free from danger to health and safety of clients, staff and visitors.
*At the time of investigation, the fire escape at the rear of the building was found to be in an unsafe condition, having rotted wood and the sections of wood that were attached to the building were splitting around the fastener which created a safety hazard. Additionally, the stair treads had nails that were popping and were uneven and did not provide a firm platform on which to step.
*The sidewalk under the fire escape was broken and cracked which created a trip hazard.
*There were loose wires hanging from an exhaust fan and from the door jamb on the porch at the rear of the building.
*There were loose wires hanging from an electrical box in the basement.
*There were loose wires hanging from a light fixture in the closet of bedroom #2 on the second floor.
*There were loose wires hanging from a light fixture on the front porch.
*There were loose and broken boards on the main stairs to the front entry and on the front porch.
*There was a growth of moss on the sidewalk on the egress path from the basement exit which created a slip hazard.
*There was evidence of water intrusion in the basement and a black substance was covering the wall nearest to the exit.
This deficiency was discussed with facility staff in order to eliminate the dangerous condition.
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Plan of Correction
The Executive Director placed caution tape at both entrances of the fire escape so that it could not be used by residents or staff. The Executive Director asked the New Castle Fire Department look at the fire escape on 4/23/19 as well as code enforcement on 4/26/19. The report from the fire department for the entire facility will be sent in a separate email to DDAP. Code enforcement reported that if any repairs or replacement would need done architectural drawings would be necessary and a building permit would be needed to make said repairs. The Code Enforcement officer stated he would send me a letter with this information which will be forwarded in a separate email to DDAP once the Executive Director has received it.
The Executive Director has arranged for bids for the fire escape and front porch, as well as removal of the black substance on the wall in the basement. With the code enforcement requirement of architectural drawings the Executive Director arranged for an engineer to provide an inspection and estimate of the work to be completed. The Executive Director will work with an architect to have the drawings completed, as well as present to the Board of Directors by 5/21/19 that the engineer also serve as the project manager and place the project out for bid a 2nd time. The Executive Director will work with the chosen project manager to report the bids to the Board of Directors so that work can begin on the project. The Executive Director will work with the chosen contractor and project director to determine the start date and estimated time to complete the project. The estimated completion of the project is October 22, 2019. The repair of the sidewalk will be included with the fire escape project.
A sample of the black substance was obtained by the Executive Director and was sent to an authorized lab for evaluation on 4/29/19. Estimated evaluation of the black substance should be received by 5/3/19 and will be reported to the DDAP by the Executive Director.
The electrical box/junction box was covered with the appropriate cover by the Executive Director on 4/11/19.
The light fixture in the closet of the 2nd floor bedroom #2 was removed by the Executive Director on 4/10/19.
The loose wires on the door jam were taped with electrical tape, and capped by the Executive Director on 4/11/19. The wire on the exhaust fan will be inspected by the Executive Director and if no power source is found the wire will be removed. If a power source is found then the wire will be tapped with electrical tape and capped by the Executive Director by 4/30/19.
The Executive Director will inspect the loose wires on the front porch have the loose wires taken care of by 5/7/19.
The growth of moss will be removed by the Operations Manager by 5/3/19.
The safety committee will meet quarterly, during this time they will do a site inspection of the inside and outside of the facility and address any maintenance or safety issues. Also, a maintenance form was created so as staff observe any maintenance or safety issue they can turn the form into their direct supervisor and appropriate repair people can be contacted. A maintenance schedule will also be created by Operations Manager and introduced to the staff by 7/15/2019. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
The facility failed to ensure that the building grounds and yard were free of hazards.
*There was a hole on the side lawn, adjacent to a drain pipe, which created a trip hazard.
*A retaining wall in the rear yard, near the smoking pavilion, was leaning forward and appeared to be in danger of falling over.
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Plan of Correction
The hole in the side lawn will be repaired by the Executive Director and Operations Manager by 5/10/19.
The retaining wall belongs the property owner behind the facility. The Executive Director discussed this with Code Enforcement as well. Once the Executive Director receives the letter from Code Enforcement the Executive Director will attempt to contact the property owner by 5/17/19. The Executive Director will meet with the Board of Directors on 5/21/19 to determine our next course of action, with a possible option being to send a letter to the property owner requesting his assistance to fix the wall. Due to the property owner being unresponsive to multiple attempted contacts, as well as a letter from code enforcement indicating that the retaining wall does not violate any local or state codes, the integrity of the wall will be monitored during quarterly safety committee site inspections.
If repairs are required the Executive Director or the Operations Manager will reach out to the property owner to address such repairs.
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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.
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Observations
The facility failed to ensure that cold food was kept at or below 40 degrees.
*The black refrigerator in the basement pantry had a temperature of 51 degrees.
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Plan of Correction
The Administrator fixed the temperature on 4/10/19 and made changes to the temperature log book with up to date temperature information on 4/26/19 so that the temperature of the refrigerators are at or below 40 degrees and continue to be checked daily at the Highland House. The log book will be checked monthly by Lead Counselor. |
705.9 (3) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(3) Limit smoking to designated smoking areas.
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Observations
The facility failed to ensure that smoking was limited to designated areas.
*There were partially consumed cigarettes found in several areas throughout the facility including the dining area and porch.
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Plan of Correction
Each resident receives an orientation packet that is reviewed with them by staff upon their admission to the facility. The HH smoking policy is included. On 4/29/19 the Administrator reviewed the smoking policy with the residents. As of 5/1/19 any partially consumed cigarette will be disposed of immediately. Should residents continue to struggle to follow this policy all residents will receive a smoking blackout. The orientation packet was updated by the Executive Director on 4/29/19. All current residents will be informed of the update on 4/30/19 by the Administrator.
The Lead Counselor will review this rule/procedure with the residence 1x a month during the house issues meeting held on Mondays. The Lead Counselor will also send out a reminder email to staff as well as let the staff know that the residents have also been re-informed. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
The facility failed to ensure that all exits were unobstructed.
The exit from the basement to the outside had a gas grill obstructing the path of egress.
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Plan of Correction
The Executive Director had the charcoal grill that was obstructing the path of egress from the basement disposed of on 4/22/19. All exits will be maintained free of obstructions effective immediately.
The safety committee will meet quarterly and do a site inspection to maintain the safety and maintenance of the facility. Necessary repairs will be scheduled by the Executive Director or the Operations Manager. A maintenance form was created that can be used by all staff to report any maintenance or safety issues to their direct supervisor. The appropriate repair person will then be scheduled by the supervisor, Executive Director or Operations Manager. A maintenance schedule will be created by the Operations Manager and introduced to the staff by 7/15/19. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
The facility failed to light all interior exits and stairs.
*The stairwell from the basement to the outside through the Bilco doors was not illuminated.
*The landing on the rear stairway between the second and third floors was not illuminated.
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Plan of Correction
The Executive Director purchased a replacement bulb for the light in the stairwell from the basement to the outside through the bilco doors. The Executive Director also contacted the alarm company, electricians and a technology company to assist with the maintenance of the lights. The final plan for this poc is estimated to be completed by 5/24/19 and will be monitored by the Executive Director, and Operations manager through its completion estimated to be 8/22/19.
The Executive Director placed a temporary light system on the rear stairway between the 2nd and 3rd floors. The Executive Director will contact electricians, alarm companies, and technology companies by 4/30/19 to schedule the light to be installed 8/22/19.
The safety committee will meet quarterly and do a site inspection, which will include monitoring the lights in all applicable areas,the lights in all applicable areas shall also be checked weekly during safety walks to maintain the safety and maintenance of the facility. Necessary repairs will be scheduled by the Executive Director or the Operations Manager. A maintenance form was created that can be used by all staff to report any maintenance or safety issues to their direct supervisor. This will assist in the periodic monitoring of all light in all applicable areas and ensure the lights, both emergency and general lighting are maintained. The appropriate repair person will then be scheduled by the supervisor, Executive Director or Operations Manager A maintenance schedule will be created by the Operations Manager and introduced to the staff by 7/15/19. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of five client records on April 11, 2019, the facility failed to document a psychosocial evaluation that included the counselor's documented clinical evaluation statement and recommendations in records, #4-5.
Psychosocial evaluation for client #4 was documented on 12/06/18.
Psychosocial evaluation for client #5 was documented on 01/07/19.
This finding was reviewed with the facility staff during the complaint investigation.
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Plan of Correction
On April 19, 2019 the Executive Director gave the counselor in charge of the indicated charts a date of 4/24/19 to accomplish the necessary documentation.
The Executive Director and Operations Manager control plan and begin to implement this plan by 5/31/19. A Program Assistant has been named Quality Control Officer and is the Point of Contact for the Quality Control Chart Check Procedure.
Quality Control Chart Check Procedure
- Chart checks are to be completed 2x a month
- All completed chart checks will be scanned to the assigned counselor, lead counselor, quality control officer, and anyone that needs to make any corrections within the chart.
- The quality control officer, will keep a master copy of the chart checks in the first-floor office. Documents that need corrections will be attached to the Master Chart Check.
- Any corrections/documentation needed must be completed within one week of the chart check. Once corrections are completed, they are to be initialed off on the master copy, documentation that was missing are to be given to the quality control officer for review and to be filed. However, should the client have already been discharged a document will be placed within the chart indicating what items/documents are missing from the chart.
- All discharged charts are to be reviewed within 5 days of the clients' discharge. Any corrections needed must be documented in a separate note within one week of the chart check. Once corrections have been provided in a separate note, they are to be initialed off on the master copy. Documentation that was completed prior to the discharge that were not filed are to be given to the quality control officer for review and to be filed.
- The quality control officer will work with the lead counselor who will address any issues that occur with this process.
- Once all deficiencies are corrected within the chart the chart will be stored at the Highland House. Once the tracking form has been completed, after 1 year, the closed chart will then be sent to the administrative office for storage.
All staff will be trained by the Lead Counselor and Quality Control Officer upon hire. The Quality Control Chart Check Procedure serves as an ongoing training tool along with the chart check sheet to ensure this issue does not occur in the future.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of five client records on April 11, 2019, the facility failed to review and update treatment plans at least every thirty days in client record #1.
Client #1 one was admitted on 12/07/18 and was active at the time of the review. Client #1's initial comprehensive treatment plan was created on 12/12/18 and the next documented update was completed on 2/14/19.
This finding was reviewed with the facility staff during the complaint investigation.
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Plan of Correction
On April 19, 2019 the Executive Director gave the counselor in charge of the indicated charts a date of 4/24/19 to accomplish the necessary documentation. A letter was placed in the counselor's chart indicating information/documentation was missing.
The Executive Director and Operations Manager will develop a more thorough quality control plan and begin to implement this plan by 5/31/19. A Program Assistant has been named Quality Control Officer and is the Point of Contact for the Quality Control Chart Check Procedure.
Quality Control Chart Check Procedure
- Chart checks are to be completed 2x a month, on the 15th and the 30th
- All completed chart checks will be scanned to the assigned counselor, lead counselor,quality control officer, and anyone that needs to make any corrections within the chart.
- The quality control officer will keep a master copy of the chart checks in the first-floor office. Documents that need corrections will be attached to the Master Chart Check.
- Any corrections/documentation needed must be completed within one week of the chart check. Once corrections are completed, they are to be initialed off on the master copy of the chart check, documentation that was missing are to be given to the quality control officer for review and to be filed. However, should the client have already been discharged a document will be placed within the chart indicating what items/documents are missing from the chart.
- All discharged charts are to be reviewed within 5 days of the clients' discharge. Any corrections needed must be documented in a separate note within one week of the chart check. Once corrections have been provided in a separate note, they are to be initialed off on the master copy. Documentation that was completed prior to the discharge that were not filed are to be given to the quality control officer for review and to be filed.
- The quality control officer will work with the lead counselor, who will address any issues that occur with this process.
- Once all deficiencies are corrected within the chart the chart check will be shredded. The chart will be stored at the Highland House. Once the tracking form has been completed, after 1 year, the closed chart will then be sent to the administrative office for storage.
All staff will be trained by the Lead Counselor and Quality Control Officer, upon hire. The Quality Control Chart Check Procedure serves as an ongoing training tool along with the chart check sheet to ensure this issue does not occur in the future. |