INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 18, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Sojourner House, 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) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill logs , the facility failed to document the completion of monthly unannounced fire drills.
A review of the fire drill logs was conducted on March 18, 2021. The fire drill log was reviewed from the time period of May 2020 to February 2021. Documentation was missing for fire drills conducted for the months of December 2020, January 2021, and February, 2021.
This is a repeat citation from the April 17, 2020 inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Program Manger will conduct a staff meeting/Training on April 21, 2021 and will review monthly fire drill procedure and fire drill log documentation. Unannounced fire drills will be conducted monthly and logged accordingly.
Once a month the Program Manager will audit the fire drill log book and will forward onto the Clinical Supervisor for final approval. POC DATE: 4/21/2021 |
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.
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Observations
Based on a review of the fire drill logs, the facility failed to document the completion of a fire drill during sleeping hours at least every 6 months.
A review of the fire drill logs was conducted on March 18, 2021. The fire drill log was reviewed from the time period of May 2020 to February 2021. An overnight was due to be conducted in February 2021. There was no documentation of an overnight fire drill for February 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Program Manger will conduct a staff meeting/Training on April 21, 2021 and will review overnight fire drill procedure and overnight fire drill log documentation. Unannounced overnight fire drills will be conducted every 6 months and logged accordingly.
Once a month the Program Manager will audit the fire drill log book, which will include overnight fire drill documentation, and will forward onto the Clinical Supervisor for final approval. POC DATE: 4/21/2021 |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to document an annual written individual staff performance evaluation in one of one personnel record.
Employee # 1 was hired as the project director on October 14, 2019. There was no documentation provided of a 2020 annual written performance evaluation.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Program Manager will conduct annual performance evaluations prior to the end of fiscal year 2021 with all staff. A written copy of the evaluation will be given to the staff person and the original will be placed in their personnel file. Clinical Supervisor will ensure that an annual evaluation for each staff member is completed and that each personnel file contains a written evaluation.
POC Date 7/1/2021 |
709.28 (a) (1) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code § 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure must include, but not be limited to:
(1) Confidentiality of client identity and records. Procedures must include a description of how the project plans to address security and release of electronic and paper records and identification of the person responsible for maintenance of client records.
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Observations
Based on the review of client records, the facility failed to ensure the confidentiality of client identity and records in one of four client records.
Client # 4 was admitted on December 31, 2020. There was information regarding another client found in this client's record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Lead Therapist will conduct a clinical staff/training meeting to review client identity/confidentially policy and procedures, filing and correct client forms. Therapists will audit their clients charts on a monthly basis and will report to Clinical Supervisor during supervision on the audits of the charts. Therapists will ensure that the information in the chart is that clients, removing the possibility of error in misfiling. Clinical Supervisor will audit charts once per month to ensure accuracy and completion of documentation.
POC Date 7/1/2021 |
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.
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Observations
Based on the review of client records, the facility failed to obtain an informed and voluntary consent in one of four client records.
Client # 2 was admitted on December 3, 2020. Information was released to a government agency. The facility failed to document a release of information for the agency.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Lead Therapist will conduct a clinical staff/training meeting on May 19, 2021 to review release of information policy and procedures with therapists, intake specialist, and service coordinators. A new general release form will be created that outlines the release(s) of information, dates effective and will be included in the intake documentation. The new form will replace the current one in the intake packet and will be reviewed by Intake Specialist during admission process. Prior to releasing any information, the staff person ( Therapist or Service Coordinator) will check clients chart for release. If one is not present, the staff will have client sign one identifying the party to whom the release will be for. Therapists will ensure all releases are properly signed and placed in the clients chart.
POC Date 7/1/2021 . |
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 the review of client records, the facility failed to document written acknowledgement the client was informed of the right that no client may be deprived of a civil right solely by reason of treatment.
Client records # 1, 2, 3 and 4 were missing written acknowledgement that clients were informed of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Lead Therapist will conduct a clinical staff/training meeting on May 19, 2021 to review client civil rights form with therapists, intake specialist, and service coordinators. A new policy will be created that outlines the client's rights and will be included in the intake documentation. The new form will replace the current one in the intake packet and will be reviewed by Intake Specialist during admission process. The client will sign the form indicating that they understand the policy and will be given a copy for their personal records. Therapists will audit their clients charts on a monthly basis and will report to Clinical Supervisor during supervision on the audits of the charts. Clinical Supervisor will audit charts once per month to ensure accuracy and completion of documentation.
POC Date 7/1/2021 |
709.30 (6) 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.
(6) Clients have the right to submit rebuttal data or memoranda to their own records.
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Observations
Based on the review of client records, the facility failed to document written acknowledgement that the client was informed of the right that clients have the right to submit rebuttal data or memoranda to their own records.
Client records # 1, 2, 3 and 4 were missing written acknowledgement that clients were informed of this right.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Lead Therapist will conduct a clinical staff/training meeting on May 19, 2021 to review release of information policy and procedures with therapists, intake specialist, and service coordinators. A new policy will be created that outlines the rights of a client to submit rebuttal data or memoranda to their record and will be included in the intake documentation. The new form will replace the current one in the intake packet and will be reviewed by Intake Specialist during admission process. The client will sign the form indicating that they understand the policy and will be given a copy for their personal records. Therapists will audit their clients charts on a monthly basis and will report to Clinical Supervisor during supervision on the audits of the charts. Clinical Supervisor will audit charts once per month to ensure accuracy and completion of documentation.
POC Date 7/1/2021 |
709.51(b)(4) LICENSURE Consent to treatment
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(4) Consent to treatment.
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Observations
Based on the review of client records, the facility failed to document a consent to treatment in two of four client records.
Client # 2 was admitted on December 3, 2020. There was no documentation of a consent to treatment.
Client # 3 was admitted on October 19, 2020. There was no documentation of a consent to treatment.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Lead Therapist will conduct a clinical staff/training meeting on May 19, 2021 to review consent for treatment documentation with therapists, intake specialist, and service coordinators. Intake Specialist will be responsible for reviewing , explaining and attaining signatures of the consents at intake. The consents will be completed prior to client meeting with Therapist to finish admission process. Therapists will audit their clients charts on a monthly basis to insure all documentation is completed, signatures are on all forms
and forms are filed correctly and will report to Clinical Supervisor during supervision on the audits of the charts. Clinical Supervisor will audit charts once per month to ensure accuracy and completion of documentation.
POC Date 7/1/2021 |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to document a physical examination in four of four client records.
Client records # 1, 2, 3 and 4 were missing documentation of a physical examination.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 20, 2019 and the September 25, 2020 licensing inspections.
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Plan of Correction
Clinical Supervisor and Lead Therapist will conduct a clinical staff/training meeting on May 19, 2021 to introduce new policy and procedure requirement of clients receiving a physical examination during the intake process . The training will include therapists, intake specialist, and service coordinators who will be responsible for scheduling the appointment at local medical clinics/facilities. Therapists will document date, time and location of appointment in paper and EMR chart, will copy report from examiner and place in chart. The physical is considered part of the intake process and will occur prior to the client becoming engaged in programming.
Date of POC 7/01/2021 |
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 the review of client records, the facility failed to document a treatment and rehabilitation plan update in two of three client records.
Client # 2 was admitted on December 3, 2020 and is still an active client. There was no documentation of treatment plan updates due to be completed by January 7 and February 7, 2021.
Client # 3 was admitted on October 19, 2020 and discharged on March 18, 2021. There was no documentation of treatment plan updates due to be completed by December 2, 2020, January 2, February 2, and March 2, 2021.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Supervisor and Lead Therapist will conduct a clinical staff/training meeting on May 19, 2021 to review the Treatment Plan process, due dates and updates. Therapists will be responsible for the creation of the treatment plan(s) with client and for keeping them up-to-date and a copy placed in the client's file. Treatment plans will be reviewed in supervision with Clinical Supervisor.
An initial treatment plan will be created by the clinician on the day of admission followed by a comprehensive treatment plan on day 21 after admission. The treatment plan will be updated every 30 days by clinician and will be monitored by the Clinical Supervisor.
POC Date 7/1/2021 |