INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 21, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Tradition 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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705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure water temperatures not exceed 120 degrees Fahrenheit. Room #20 bathroom water temperature was measured at 136 degrees Fahrenheit.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Maintenance was onsite day of inspection and regulated water temperature to code. Maintenance and risk committee will continue to monitor water temperatures as required and will report any areas or concern to Executive Director. |
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.
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Observations
Based on a physical plant inspection, the facility failed to operate an onsite food preparation area or a central food preparation area to include storing all food items off the floor. A Container storing food was on the floor in the dry storage area.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director met with BHT Supervisor on June 27, 2023 to review deficiency. Discussed daily monitoring of food regulation. Risk committee will monitor during monthly facility walk through and will report any issues. Executive Director will address any ongoing issues during monthly supervision with BHT Supervisor. |
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 one of one applicable client records reviewed, the facility failed to provide documentation of the emergency contact being notified when a client leaves against medical advice in accordance with the facility policy and procedure manual. The facility policy and procedure indicate the emergency contact be notified of the client leaving against medical advice no later than 12 hours after the client left and document in the client record.
Client # 6 was admitted on March 10, 2023 and was discharged on March 29, 2023. There was no documentation of the emergency contact being notified of the client leaving against medical advice in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor will review protocol for notifying emergency contact when a client leaves treatment against facility advice, during clinical staff meeting on July 11, 2023. Executive Director and Clinical Supervisor will review this while completing discharge chart audits to ensure ongoing compliance. |
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 three of five applicable client records reviewed, the facility failed to review and update the treatment and rehabilitation plan at least every sixty days in client records # 1, 2 and # 3.
Client # 1 was admitted on April 21, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on May 1, 2023. A treatment and rehabilitation plan update was due no later than June 1, 2023. A treatment and rehabilitation plan update did not occur until June 10, 2023.
Client # 2 was admitted on April 3, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on April 4, 2023. A treatment and rehabilitation plan update was due no later than May 4, 2023. A treatment and rehabilitation plan update did not occur until May 14, 2023. A treatment plan update was due June 14, 2023. There was no documentation of a treatment plan update in the client record.
Client # 3 was admitted on April 21, 2023 and was still active at the time of the inspection. A treatment and rehabilitation plan was developed on April 22, 2023. A treatment and rehabilitation plan update was due no later than May 22, 2023. A treatment and rehabilitation plan update did not occur until June 5, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor will review treatment plan updates with clinicians during clinical staffing on July 11, 2023. She will monitor compliance during monthly chart audits. Any ongoing issues with be address by clinical supervisor during monthly supervision. |
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 one of three applicable client records reviewed, the facility failed to provide follow-up information in accordance with the facility policy and procedure manual. The facility policy and procedure manual indicate a follow-up to occur within seven days after discharge by phone.
Client # 6 was admitted on March 10, 2023 and was discharged on March 29, 2023.
There was no follow-up information available in the client record.
Client # 7 was admitted on February 20, 2023 and was discharged on May 24, 2023.
There was no follow-up information available in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor reviewed follow up policy with administrative assistant on June 28, 2023. Discussed documenting within seven days of discharge. Discussed documenting if there was no forwarding information for the client, if they were unable to be reached. Executive Director and Clinical Supervisor will review compliance during monthly chart audits. Any additional concerns will be addressed in monthly supervision with the Executive Director. |
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 seven of seven client records reviewed, the facility failed to provide a complete client record to include verification that work done by the client at the project is an integral part of their treatment and rehabilitation plan.
Client # 1 was admitted on April 21, 2023 and was still active at the time of the inspection. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 2 was admitted on April 3, 2023 and was still active at the time of the inspection. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 3 was admitted on April 21, 2023 and was still active at the time of the inspection. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 4 was admitted on May 2, 2023 and was still active at the time of the inspection. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 5 was admitted on April 12, 2023 and was discharged May 3, 2023. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 6 was admitted on March 10, 2023 and was discharged March 29, 2023. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
Client # 7 was admitted on February 20, 2023 and was discharged May 24, 2023. Verification that work done by the client at the project was not part of their treatment and rehabilitation plan.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Executive Director and Clinical Supervisor will review utilization of work therapy in individual treatment plans at clinical team meeting on July 12, 2023. Clinical staff will ensure work therapy is added to treatment plans detailing involvement in employment, volunteer work, or life skills. Executive Director and Clinical Supervisor will complete monthly chart audits to review progress. Clinical supervisor will address any ongoing concerns during individual supervision. |