INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 18, 2023, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Libertae Family House Libertae, 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:
|
Plan of Correction
|
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of five personnel records, the facility failed to ensure that one employee received the minimum of 4 hours of TB/STD training and 6 hours of HIV/AIDS training within the regulatory timeframe.
Employee # 5 was hired as a counselor on May 31, 2022 and was due to have the communicable disease trainings no later than May 31, 2023. However, the HIV/AIDS training was not documented as complete until November 12, 2023 and the TB/STD training was not documented as complete until October 2, 2023.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The deficiency shall be corrected by the administrative assistance of the project, who shall maintain a spreadsheet of all employees to track agency compliance with training requirements. Personnel who are not meeting training requirements on schedule are reminded to register for upcoming trainings. Personnel who have completed trainings are instructed to submit documentation to the administrative assistant to be filed in personnel records.
To ensure that the deficiency does not reoccur, the administrative assistant is responsible to monitor the compliance of all counseling staff with completing mandatory training requirements within one year of employment and at least one month in advance of the deadline. She is required to furnish a monthly report to her supervisor indicating dates of enrollment in mandatory trainings, dates of completion of mandatory trainings, and any non-compliance by staff with completing any mandatory trainings well before the required time frame.
|
705.7 (b) (6) 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:
(6) Store all food items off the floor.
|
Observations
Based on a physical plant inspection on December 18, 2023, the facility failed to store all food items off the floor as a 50-pound bag of sugar was found on the floor of the pantry.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
To provide safe and sanitary storage of all foods, the food service workers, clients, and other staff of the facility who are in the kitchen working with any type of food, are responsible to adhere to the food safety requirements, and to follow proper sanitation and food handling practices.
The facility has a pantry for food storage. All food shall be stored at least six inches off the floor. This will be done by keeping all food on shelves. After the preparation of every meal, the pantry and shelving will be inspected by staff, especially for containers of food stored on the floor.
The facility shall correct this deficiency by educating and informing all those who work in the kitchen areas of this policy. The correction shall be maintained by facility staff who will be appointed to check the food storage areas for proper food containment on a daily basis and especially after the preparation of meals.
|
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.
|
Observations
Based on a review of fire drill logs from November 2022 through October 2023, the facility failed to conduct fire drills during sleeping hours at least every six months.
Based on the program schedule provided by facility staff, the facility sleeping hours are 11:00 P.M. through 05:30 A.M. No fire drills between November 2022 and August 2023 were conducted between those hours.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
So that all employees, visitors, and clients of Libertae know what to do in the event of a fire, Libertae conducts unannounced fire drill practices according to a schedule only aware to the Treatment Tech Supervisor, who maintains a record of the fire drill practices.
It is the responsibility of the Treatment Tech Supervisor to oversee all Fire/Emergency Building Evacuation plans and procedures and to review them periodically to monitor the agency's performance regarding safety and emergency preparedness.
The deficiency has been corrected. The fire drill protocol was reviewed with operations staff. Unannounced fire drills have been scheduled and will be held during sleeping hours every six months, in the months of January and June of 2024.
The Quality Assurance Committee will review the findings of all fire drill reports monthly.
Any deficiencies discovered will be addressed by in-service training of staff. New staff are trained in facilitating fire drills upon hiring and orientation. Fire drill logs will be available for inspection.
|
709.22 (c) LICENSURE Governing Body
§ 709.22. Governing body.
(c) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to, a statement disclosing the names of officers, directors and principal shareholders, when applicable.
|
Observations
The facility failed to document that an annual report for 2022 was completed and made available to the public.
This finding was reviewed with facility staff during the licensing process.
|
Plan of Correction
The deficiency has been corrected. An annual report was made available to the public at the end of year 2023. It includes a disclosure of governing board officers and directors. It also includes a donor list.
The report shall be available on the agency website and a hardcopy was furnished to all of the agency's stakeholders and contacts in the agency's database.
The facility will ensure that the deficiency does not reoccur by scheduling the production of the annual report for November 2024. This is the responsibility of the facility director. |
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.
|
Observations
Based on a review of seven client records, the facility failed to obtain a complete informed and voluntary consent from the client of the disclosure of information in the client record in all seven records reviewed. The facility failed to ensure that client signed consent to release information forms to the laboratory were compliant with the 42 CFR 2.31(a)(6) requirement to include a statement that the consent is subject to revocation at any time except to the extent that the project has already acted in reliance on it.
This is a repeat citation from the November 16-17, 2022 annual licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The deficiency has been corrected. The consent form for the lab services which the facility employs has been modified to include the statement:
"I understand that my records are protected under the Federal regulations governing confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR, Part 2, and cannot be disclosed without my written consent unless otherwise provided by the regulations. I also understand that I may revoke this written consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
This consent expires 30 days after my discharge or when specified here: _______"
It is the responsibility of the manager of admissions to obtain informed and voluntary consents to disclose information to the laboratory.
The consent to release information form must include the date, event, or condition upon which the consent will expire. The staff person who completed these forms has now been retrained on this procedure. Records will be reviewed for completeness, adequacy, and accuracy at regularly scheduled meetings with supervisor.
It is the responsibility of the Manager of Admissions to implement and maintain this correction.
|
709.28 (c) (6) 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:
(6) Date, event or condition upon which the consent will expire.
|
Observations
Based on a review of seven client records, the facility failed to ensure that consent to release information forms included the date, event, or condition upon which the consent will expire in all seven records reviewed.
The facility failed to ensure that client signed consent to release information forms to their funding source contained the date, event, or condition upon which the consent will expire.
This is a repeat citation from the January 5-6, 2022, and November 16-17, 2022 annual licensing inspections.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The deficiency has been corrected. The Project Director has reviewed all disclosure of information forms used by the agency. The consent forms have been modified to include the statement:
"I understand that my records are protected under the Federal regulations governing confidentiality of Alcohol and Drug Abuse Patient Records, 42 CFR, Part 2, and cannot be disclosed without my written consent unless otherwise provided by the regulations. I also understand that I may revoke this written consent at any time except to the extent that action has been taken in reliance on it, and that in any event this consent expires automatically as follows:
This consent expires 30 days after my discharge or when specified here: _______"
It is the responsibility of the manager of admissions to obtain informed and voluntary consents to disclose information and ensure that the expiration date is recorded on each form prior to obtaining the client's signature.
The consent to release information form must include the date, event, or condition upon which the consent will expire. The staff person who completed these forms has now been retrained on this procedure. Records will be reviewed for completeness, adequacy, and accuracy at regularly scheduled meetings with supervisor.
It is the responsibility of the Manager of Admissions to implement and maintain this correction.
|
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within 21 days of admission, per facility policy, in four of seven applicable records reviewed.
Client # 1 was admitted on August 30, 2023 and was discharged on November 1, 2023. The record did not contain a psychosocial evaluation.
Client # 5 was admitted on September 28, 2023 and was active at the time of the inspection. The record did not contain a psychosocial evaluation.
Client # 6 was admitted on November 7, 2023 and was active at the time of the inspection. The psychosocial evaluation was not completed until December 5, 2023.
Client # 7 was admitted on June 6, 2023 and was discharged on October 25, 2023. The psychosocial evaluation was not completed until July 17, 2023.
These finding were discussed with facility staff during the licensing process.
|
Plan of Correction
It is the policy of Libertae to ensure that a complete client record is maintained. This includes psychosocial evaluations, which are to be completed within 21 days of admission. The psychosocial evaluation is signed and dated by the therapist of record and added to the client file.
In cases where the client has not completed the psychosocial evaluation for any reason, such as an abrupt discharge from treatment, a note will be made in the client's record, on the psychosocial evaluation form.
This deficiency shall be corrected by the Program Director by February 9, 2024, who shall advise the therapists of the requirement, and implement a record review procedure.
The correction will be maintained by the Program Director, who will review each client's file within the 21-day time frame for entering the psychosocial evaluation into the record. The Program Director shall utilize an audit checklist to account for documentation.
This checklist is reviewed quarterly by the Quality Assurance committee of the facility. Corrective action will be taken whenever a deficiency is noted.
|
709.52(a) LICENSURE Individual TX and REHAB Plan
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
|
Observations
Based on a review of client records and the facility ' s policies and procedures, the facility failed to ensure that an individual treatment and rehabilitation plan was developed with the client within 14 days of admission, per the facility policy, in four of seven applicable records reviewed.
Client # 1 was admitted on August 30, 2023 and was discharged on November 1, 2023. The individual treatment and rehabilitation plan was completed on September 1, 2023; however, there was no documentation that it was developed with the client.
Client # 2 was admitted on April 18, 2023 and was discharged on October 14, 2023. The individual treatment and rehabilitation plan was completed on April 21, 2023; however, there was no documentation that it was developed with the client.
Client # 3 was admitted on February 27, 2023 and was discharged on May 8, 2023. The individual treatment and rehabilitation plan was completed on February 28, 2023; however, there was no documentation that it was developed with the client.
Client # 5 was admitted on September 28, 2023 and was active at the time of the inspection. The individual treatment and rehabilitation plan was completed on September 28, 2023; however, there was no documentation that it was developed with the client.
The findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The treatment provider shall begin to formulate a preliminary treatment and rehabilitation plan upon intake and assessment. At this time a history is taken, and psychosocial evaluation is provided.
Documentation of the finalized individual treatment and rehabilitation plan that has been developed in collaboration with the client is to be included in the client record. The treatment plan shall be signed and dated by the individual rendering services. It shall also be documented that the treatment plan was developed with the client.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records. The Program Director will review the policy with all agency treatment providers by February 9, 2024.
Client records will be reviewed at regularly scheduled supervision meetings with the Program Director. Records will be reviewed for completeness, adequacy, and accuracy.
The Quality Assurance Committee will also conduct a quarterly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported to the Program Director for corrective action.
|
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
|
Observations
Based on a review of client records and the facility ' s policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include case consultation information quarterly, per facility policy, in one of two applicable records reviewed.
Client # 7 was admitted on June 6, 2023 and was discharged on October 25, 2023. There was no documentation of case consultation information in the record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
It is the responsibility of the therapist of record to enter the documentation into the client charts.
Each client's progress shall be reviewed at least quarterly, and more frequently if needed, at a case conference attended by a multidisciplinary team.
Documentation of the case consultation shall be noted in the client's record by the counselor rendering treatment services.
Staff who render treatment services are required to adhere to the program's policy and procedures regarding the completion of client records.
The Project Director will review the policy with all agency treatment providers by February 9, 2024.
Client records will be reviewed at regularly scheduled supervision meetings with the Project Director. Records will be reviewed for completeness, adequacy, and accuracy.
The Quality Assurance Committee will also conduct a quarterly case review of five active client records.
Adherence to the requirements regarding client records will be verified and any problems will be reported to and addressed by the Project Director for corrective action.
|
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.
|
Observations
Based on a review of client records, the facility failed to ensure a complete client record on an individual which includes information relative to the client's involvement with the project, including an aftercare plan, in one of three applicable records reviewed.
Client # 2 was admitted on April 18, 2023 and was discharged on October 14, 2023. The client record did not contain documentation of a completed aftercare plan.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The client record shall contain an aftercare plan, if applicable. The aftercare plan shall be developed for the client to follow after she leaves formal treatment. It is the client's individual plan for the future, including an identification of the client's personal goals and objectives. It shall focus on sustaining and building on the progress achieved during treatment and shall have input from all significant persons, especially the client.
Staff who render treatment services are required to adhere to the program's policy regarding the completion of client records.
The Program Director will review the policy with all agency treatment providers by February 9, 2024. Client records will be reviewed at regularly scheduled supervision meetings with a supervisor. Records will be reviewed for completeness, adequacy, and accuracy.
The Quality Assurance Committee will also conduct a quarterly case review of five active client records. Adherence to the requirements regarding client records will be verified and any problems will be reported to the Program Director = for corrective action.
|
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.
|
Observations
Based on a review of client records and the facility ' s policies and procedures, the facility failed to ensure a complete client record included information relative to the client's involvement with the project, to include follow-up information within one week of discharge, per facility policy, in two of five applicable records reviewed.
Client # 1 was admitted on August 30, 2023 and was discharged on November 1, 2023. The client record did not contain documentation of follow-up information.
Client # 3 was admitted on February 27, 2023 and was discharged on May 8, 2023. The client record did not contain documentation of follow-up information.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
The client record shall contain follow-up information. When a client has been discharged the project shall, with the written consent of the client and within one week from the day the client has discharged, attempt to contact the client to determine her disposition at one-week post-discharge. Once the attempt has been made and documented, the project shall consider its obligation to the individual fulfilled.
Staff who render treatment services are required to adhere to the program's policy and procedures regarding the completion of client records.
The Project Director will review the policy and procedures with all agency treatment providers by February 9, 2024.
Client records will be reviewed at regularly scheduled supervision meetings with the Project Director. Records will be reviewed for completeness, adequacy, and accuracy.
The Quality Assurance Committee will also conduct a quarterly case review of five active client records.
Adherence to the requirements regarding client records will be verified and any problems will be reported to the Project Director for corrective action.
|
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
|
Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
A plan of correction for ensuring consent to release information forms contained a date, event, or condition of expiration was submitted and approved by the Department for the January 5-6, 2022 and November 16-17, 2022 annual licensing inspections. Consent to release forms missing the date, event, or condition of expiration was again found to be a deficiency in the December 18, 2023 licensing inspection.
A plan of correction for ensuring complete consent to release information forms were obtained prior to the disclosure of information was submitted and approved by the Department for the November 16-17, 2022 annual licensing inspection. Complete consent to release forms was again found to be a deficiency in the December 18, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
It is the responsibility of the Facility Director to make sure all plans of correction are implemented by February 9, 2024.
The plans of correction that have been implemented will be monitored on a quarterly basis using an audit tool developed to track the required changes.
The Program Manager, who is a member of the Quality Assurance committee, will ensure routine monitoring and report any discrepancies or non-compliance to the Facility Director for corrective action.
|