INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 15, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Catholic Charities Diocese of Harrisburg, PA Inc. 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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705.10 (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 fire drill logs from September 2023 through June 2024 the facility failed to document the time of the drill and the amount of time it took for evacuation for the November 2023 fire drill. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Fire drill procedures were reviewed during the 07/17/2024 staff meeting. Staff was reminded to note both the time of drill and length of drill.
Program Director monitors fire drills monthly for completion, accuracy and to ensure they are documented correctly.
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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.
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Observations
Based on a review of residential client records, the facility failed to follow the written procedures for the management of treatment/rehabilitation services for clients in one of three applicable client records reviewed.The facility policy and procedure manual stated that the emergency contact will be notified no later than 12 hours after a client is discharged from the facility against medical advice, per the requirement in DDAP Licensing Alert 02-21.Client #7 was admitted to the inpatient non-hospital rehabilitation activity on April 1, 2024, and was discharged against medical advice on May 7, 2024. There was no documentation that the emergency contact was notified of the client's discharge from the facility against medical advice as of the date of the inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Discharge procedures include the notification of the emergency contact within 12 hours unless release of information has been revoked.
Director will review procedures with clinical staff by 8/31/24 as well as all staff at the September staff meeting.
Program Director will review discharges during supervision bi-weekly to ensure they are completed accurately and in accordance with agency policy. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form that is to include the name of the person, agency or organization to whom disclosure is made in four of seven records reviewed. Client #1 was admitted on May 7, 2024 and was still active at the time of the inspection. A consent to release was signed and dated on May 7, 2024 that failed to include the name of the person, agency or organization to whom disclosure is made. Client #3 was admitted on January 30, 2024 and was still active at the time of the inspection. A consent to release was signed and dated on January 30, 2024 that failed to include the name of the person, agency or organization to whom disclosure is made. Client #4 was admitted on April 24, 2024 and was still active at the time of the inspection. A consent to release was signed and dated on April 24, 2024 that failed to include the name of the person, agency or organization to whom disclosure is madeClient #5 was admitted on October 26, 2023 and was discharged on March 10, 2024. A consent to release was signed and dated on October 26, 2023 that failed to include the name of the person, agency or organization to whom disclosure is madeThis finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Examples of ROIs are included in the Master Example Book in the main office.
During the 7/17/2024 completion of correct ROIs was reviewed. The importance of accurate, complete and detailed information was emphasized.
Director will review ROIs during bi-weekly supervision with clinical staff. |
709.28 (c) (3) 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:
(3) Purpose of disclosure.
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Observations
Based on the review of client records, the facility failed to document a completed consent to release information form that is to include the purpose of the disclosure that is made in two of seven records reviewed. Client #1 was admitted on May 7, 2024 and was still active at the time of the inspection. A consent to release was signed and dated on May 7, 2024 for a family member that failed to include the purpose of the disclosure. Client #6 was admitted on February 6, 2024 and was discharged on July 1, 2024. A consent to release was signed and dated on April 12, 2024 to an individual that failed to include the purpose of the disclosure. This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Examples of ROIs are included in the Master Example Book in the main office.
During the 7/17/2024 completion of correct ROIs was reviewed. The importance of accurate, complete and detailed information was emphasized.
Director will review ROIs during bi-weekly supervision with clinical staff. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to ensure that there was appropriate documentation of written acknowledgment by the client that the client had been made aware of their rights in seven out of seven client records reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consent to treatment includes acknowledgement of "Basic Rights and Responsibilities." This will be updated to read "Client's Rights and Responsibilities" as indicated on the policy.
Consent will be reviewed with intake and clinical staff by 8/31/24 to ensure it is signed and in the file at admission.
Consents will be reviewed by the Program Director to ensure accuracy and completeness during bi-weekly supervision. |
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.
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Observations
Based on a review of client medication administration records, the facility failed to document the reasons medication was not given as prescribed. The medication administration record was not signed to verify the client received the medication as prescribed nor was there a reason documented for the missed medication in six out of six client records reviewed.Client #1 was admitted on May 7, 2024 and was still active at the time of the inspection. There was no documentation for missed doses of medication for the following: Quetiapine Fumarate 50 mg 1 tab daily on May 25 and 26, 2024 and June 16 and 18, 2024. Ropinirole hcl - 5 mg 1 tab daily on June 11 and 18, 2024. Client #3 was admitted on January 30, 2024 and was still active at the time of the inspection. There was no documentation for missed doses of medication for the following:Zubsolv 11.4 mg 2x daily on May 17, 2024 Topiramate 50 mg 2x daily on April 12, 2024 Buspirone HCL 30 mg 2x daily on May 31, 2024Client #4 was admitted on April 24, 2024 and was still active at the time of the inspection. There was no documentation for missed doses of medication for the following:Paroxetine 20 mg daily on April 27, 2024, May 16, 17, 23 and 24, 2024Xarelto 20 MG daily on April 27, 2024Citalopram 20 mg daily on June 8, 10, and 11, 2024 Ropinirole 25 mg daily on June 13, 2024. Client #5 was admitted on October 26, 2023 and discharged on March 10, 2024. There was no documentation for missed doses of medication for the following:Buprenorphine 8 mg 3x daily on December 23, 2023 Client #6 was admitted on February 6, 2024 and discharged on July 1, 2024. There was no documentation for missed doses of medication for the following:Atorvastatin 20 mg 1x daily on May 28, 2024.Client #7 was admitted on April 1, 2024 and discharged on May 7, 2024. There was no documentation for missed doses of medication for the following:Aripiprazole 15 mg on April 7, 2024 paliperidone 6 mg on April 4, 5, 7, 9, 22, 23, 24, 27, 29, 2024Quetiapine 100mg on April 23, 2024 loratadine tablet on April 27 and 28, 2024 valacyclovir 500 mg on May 5, 2024. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medication errors found during the inspection were reviewed at the staff meeting on 07/17/2024. Procedures for documenting medication administration was reviewed.
All staff will be re-trained on medication procedures and policies by 09/15/2024.
Medication records will be reviewed weekly by the Lead RA and Program Director to ensure medication administration is documented accurately.
Program Director and Lead RA will review medication logs weekly to ensure missed medications are documented on the proper form notating the reason medication was not administered. |
709.51(b)(2)(i) LICENSURE Client Orientation to Project
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(2) Client orientation to the project which includes, but it is not limited to, a familiarization with:
(i) Project policies.
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Observations
Based on a review of client records, the facility failed to document that client orientation had taken place in seven out of seven client records reviewed.Client #1 was admitted on May 7, 2024 and was still active at the time of the inspectionClient #2 was admitted on May 9, 2024 and was still active at the time of the inspection. Client #3 was admitted on January 30, 2024 and was still active at the time of the inspection.Client #4 was admitted on April 24, 2024 and was still active at the time of the inspectionClient #5 was admitted on October 26, 2023 and was discharged on March 10, 2024. Client #6 was admitted on February 6, 2024 and discharged on July 1, 2024Client #7 was admitted on April 1, 2024 and was discharged on May 7, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At admission, intake and/or clinical staff review the house rules, client rights & responsibilities, grievance policy, emergency procedures, discharge criteria and potential additional costs.
At admission clients sign the consent to treatment acknowledging their review of the above.
Consent will be reviewed with intake and clinical staff by 8/31/24 to ensure it is signed and in the file at admission.
Program Director will review client orientation during bi-weekly supervision and ensure it is completed and documented correctly in the file. |
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 the review of client records, the facility failed to document a psychosocial evaluation in three out of seven client records. Client #2 was admitted on May 9, 2024 and was still active at the time of the inspection. Client #5 was admitted on October 26, 2023 and was discharged on March 10, 2024 . Client #7 was admitted on April 1, 2024 and was discharged on May 7, 2024..These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director will review psychosocial procedures with all clinical staff by 8/31/2024.
Program Director will ensure during bi-weekly supervision that psychosocials are completed and included in the documentation.
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709.51(b)(7) LICENSURE Preliminary Tx. Plan.
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(7) Preliminary treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to document a preliminary treatment plan in seven out of seven client records reviewed. Client #1 was admitted on May 7, 2024 and was still active at the time of the inspectionClient #2 was admitted on May 9, 2024 and was still active at the time of the inspection. Client #3 was admitted on January 30, 2024 and was still active at the time of the inspection.Client #4 was admitted on April 24, 2024 and was still active at the time of the inspectionClient #5 was admitted on October 26, 2023 and was discharged on March 10, 2024. Client #6 was admitted on February 6, 2024 and discharged on July 1, 2024Client #7 was admitted on April 1, 2024 and was discharged on May 7, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility's policy is to include a preliminary treatment plan prior to treatment plan being developed in 15 business days.
Program Director will review policy with all clinical staff by 08/31/2024.
Program Director will ensure preliminary treatment plan is developed for all clients during the intake process.
Program Director will review initial treatment plans during bi-weekly supervision. |
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 client records, the facility failed to document treatment plan updates within the regulatory timeframe in three out of six applicable client records reviewed.Client #1 was admitted on May 7, 2024 and was still active at the time of the inspection. The comprehensive treatment plan was completed on May 30, 2024 and an update was due no later than June 30, 2024; however, no update was documented at the time of the inspection . Client #2 was admitted on May 9, 2024 and was still active at the time of the inspection. A treatment plan update was completed on May 30, 2024 and the next update was due no later than June 30, 2024; however, no update was documented at the time of the inspection Client #6 was admitted on February 6, 2024 and discharged on July 1, 2024. A treatment plan update was completed on May 4, 2024 and the next update was due no later than June 4, 2024; however, no update was documented at the time of the inspection. These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director will review treatment plan review policies, procedures and deadlines with all clinical staff by 8/31/24.
Program director will review treatment plans during bi-weekly supervision and will ensure treatment plans are updated every 30 days. |
709.53(a)(9) LICENSURE Aftercare plans
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:
(9) Aftercare plan, if applicable.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include aftercare information in one out of three applicable discharged records reviewed.Client #6 was admitted on February 6, 2024 and discharged on July 1, 2024This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review discharge policies, procedures and timeframes with clinical staff by 8/31/2024.
Program Director will review aftercare plans during bi-weekly supervision to monitor client discharge data. Program Director will insure that appropriate aftercare information is indicated in discharge plans during bi-weekly supervision. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a discharge summary in three out of three client records reviewed. Client #5 was admitted on October 26, 2023 and was discharged on March 10, 2024. Client #6 was admitted on February 6, 2024 and discharged on July 1, 2024Client #7 was admitted on April 1, 2024 and was discharged on May 7, 2024.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review Discharge Policies and Procedures with clinical staff by 8/31/2024.
Program Director will review discharges during bi-weekly supervision to ensure that discharge summaries are included and contain appropriate clinical information. |
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 client records, the facility failed to provide a complete client record, which is to include follow-up information in two out of two discharged records reviewed.Client #5 was admitted on October 26, 2023 and was discharged on March 10, 2024. Client #6 was admitted on February 6, 2024 and discharged on July 1, 2024These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director will review client follow up policies and procedures with all clinical staff by 8/31/2024.
Program Director will ensure during discharge review that follow up information is filed appropriately.
Program Director will review monthly follow up log to ensure they are completed appropriately. |
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 document that all work done by clients at the project is an integral part of his treatment and rehabilitation plan in all seven client records. These findings were discussed with facility staff during the inspection process.
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Plan of Correction
Program Director will review Treatment Planning with all clinical staff by 09/30/2024.
Program Director will ensure when signing all treatment plans that all treatment work, reality therapies and modalities used in treatment are included in the treatment plan. |