INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 23, 2015 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 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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704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
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Observations
Based on a review of personnel records and the Staffing Requirements Facility Summary Report (SRFSR), the facility failed to ensure that each counselor met the qualification for the position of counselor.
The findings included:
On December 23, 2015 four personnel records were reviewed for documentation of the qualifications for the position of counselor.
The facility failed to ensure that each counselor met the qualification for the position of counselor, specifically employee # 3.
Employee # 3 was hired as a counselor on 5/11/2015 .
Employee # 3 has a qualifying Associates's degree; however, the reviewed documentation did not indicate 2 years of clinical experience.
The facility director confirmed that the record for employee #3 lacked documentation of 2 years of clinical experience.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective 1/1/2016 Employee #3 was moved into the position of Counselor Assistant and shall remain in that position until which time he has successfully completed two years of clinical experience. Going forward the Facility Director shall ensure that each counselor meets the qualifications for the position of counselor. |
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
A physical plant inspection was conducted on December 23, 2015. The facility failed to keep the grounds in good repair at all times.
The findings include:
Based on a physical plant inspection with the clinical director, the facility failed to supply the residents rooms with privacy blinds.
Men's Residential Room #one, no blinds in window above bed D.
Men's Residential Room #two, no blinds in window above bed B and D.
Men's Residential Room #three, no blinds in window above bed F.
Based on a physical plant inspection with the clinical director, the facility failed to ensure proper and safe ventilation in the residential rooms. Room #3 had ventilation in the upper right corner of the room with broken pieces missing causing it to be unsafe.
These findings were reviewed with the facility staff during the licensing process.
Based on an observation during the physical plant inspection, it was determined that the project failed to maintain all structures on the grounds of the facility so as to be free from any danger to health or safety in one of the group counseling rooms.
The findings were:
An inspection of the residential portion of the facility conducted on December 23, 2015 it was observed that in the "CBG" room used for Group Therapy which is a large group room located in the project's residential building , there were multiple ceiling tiles broken and cracked. There was plaster damage on the lower wall leading to the door outside.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
In lieu of Privacy Blinds, and with the approval of the auditors, the Maintenance Supervisor on 1/15/16 frosted the windows in Residential Room # 1 above Bed D , #2 above B & D, and also Room #3 above Bed F.
Maintenance staff on 1/15/16 repaired
the ventilation and removed the broken pieces in the upper right hand corner of Residential Room #3.
Maintenance staff on 1/15/16 repaired the plaster damage and fixed the tiles in the CBG room and on the lower wall leading to the door outside.
Going forward the Maintenance Supervisor shall ensure that a weekly physical plant is conducted to identify and repair physical plant issues. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection on December 23, 2015, the facility failed to ventilate the residents female bathroom by an exhaust fan or window.
The findings include:
Based on a physical plant inspection with the clinical director, the ventilation fan above the female bathroom stall was broken with no ventilation coming out. Pieces were missing off of the ventilation.
These findings were reviewed with the facility staff during the physical plant inspection.
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Plan of Correction
The ventilation fan above the female bathroom stall was repaired by Maintenance staff and is now fully functional.
The Maintenance supervisor shall ensure that a weekly physical plant inspection is conducted to identify and repair physical plant issues. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plan inspection on December 23, 2015, the facility failed to ensure all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.
The findings include:
Based on a physical plant inspection with the clinical director, the fire extinguisher located near the kitchen was expired. The fire extinguisher was last inspected on September 2014.
These findings were reviewed with the facility staff during the physical plant inspection
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Plan of Correction
The fire extinguisher located near the kitchen in the AOD unit was a loaner from the fire extinguisher company and it has been replaced and inspected on 1/20/2016. The tag reflects the updated inspection.
Going forward the Maintenance Supervisor shall ensure that all fire extinguishers are inspected and approved annually by the fire extinguisher company. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
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Observations
Based on a physical plant inspection, the facility failed to keep counseling doors locked where confidential client records are kept.
The findings include:
A physical plant inspection was conducted on December 23, 2015. The facility failed to keep two out of three counseling doors locked. Inside the first counseling room that was left unlocked and unattended there were confidential client files opened on the counselors desk.
These findings were discussed with the facilty 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/counselor assistant's desk.
The Clinical Supervisor shall make periodic checks of offices to ensure this procedure/practice is being adhered to. |
709.53(a)(3) LICENSURE Records of Service
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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete client record, including record of service and progress notes in nine of twelve client records.
The findings include:
Twelve client records were reviewed on December 23, 2015. Nine client records, # 1, 2, 3, 5, 6, 9, 10, 11, and 12, failed to document a record of service or progress notes.
Client # 1 was admitted on 11-16-15. The record of service for the client was missing in clients record.
Client #2 was admitted on 10-29-15. The record of service for the client was missing from clients record.
Client #3 was admitted on 11-16-15. The record of service for the client was missing from clients record.
Client #5 was admitted on 10-27-15. A record of services documented group counseling occurred on 10-28-15, 10-28-15, 10-29-15, 10-29-15, 10-30-15, 10-30-15, but there were no corresponding group notes documented for those dates.
Client #6 was admitted on 10-26-15. A record of service documented group counseling occurred on 10-27-15, 10-27-15, 10-28,15, 10-28-15, 10-29-15, 10-30-15, 10-31-15, 10-31-15, but there were no corresponding group notes documented for those dates.
Client #9 was admitted on 10-29-15 and discharged on 12-18-15. A record of service documented group counseling sessions that occurred on 12-1-15 and 12-3-15 but there were no corresponding group notes documented for those dates.
Client #10 was admitted on 10-9-15 and discharged on 11-2-15. The record of service documented counseling services that occurred on 10-10-15, 10-11,15 and 10-12-15 but there were no corresponding group notes documented for those dates.
Client #11 was admitted on 10-2-15 and discharged on 11-30-15. The record of service documented group counseling sessions that occurred on 10-21-15, 10-28-15,11-4-15,11-9-15 but there were no corresponding group notes documented for those dates.
Client #12 was admitted on 6-30-15 and discharged on 7-10-15. The record of service documented group counseling sessions that occurred on 6-30-15, 7-1-15, and 7-2-15 but there were no corresponding group notes documented for those dates.
These findings were discussed with the facility staff during the licensing process.
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Plan of Correction
The Record of Service has now been placed in Client #1, Client #2, and Client #3 File.
A record documenting group counseling and corresponding group notes is now documented in Client # 5, Client #6, Client #9, Client #10, and Client #11 files.
The Clinical Supervisor has met with all Clinical Staff and has presented the protocol to staff to follow regarding client charts.
A sign-in sheet for individual sessions shall be turned in within 24 hours after the session, and the service log is to be maintained/updated on a daily basis and kept in the resident's chart. At no time shall the record of service be removed from the chart.
The Clinical Supervisor shall do weekly chart checks to ensure that this mandatory protocol/procedure is being followed.
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