INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 5-7, 2024 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of administration information, the facility failed to collect feedback on completed trainings.
The training year beginning July 1, 2022, through June 20, 2023, was reviewed and feedback was not collected for any training.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director will complete a revised comprehensive staff development program that will be reflected in the policies and procedures by 4/15/2024. The Executive Director will document in the policies and procedures the designated staff responsible for reviewing employees' training to ensure the feedback form is completed for all training. All employees will use the Sojourner House Training Feedback Form and complete the document at the end of each training session. The designated staff members responsible for collecting the training feedback form will review the employees' training files twice a year to ensure the completion of feedback forms for each training session. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administration information, the facility failed to complete an annual evaluation of the overall training plan.
There was no annual evaluation of the overall training plan provided for training year July 1, 2022-June 30, 2023.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The Executive Director will complete a revised comprehensive staff development program that will be reflected in the policies and procedures by 4/15/2024. The Executive Director will send an annual training survey to all staff by June 15th of each fiscal year to receive feedback on completed training and track recommendations for new training for the upcoming fiscal year. The annual training plan will summarize the feedback and training recommendations. The executive director will complete the annual training plan for the new fiscal year by July 1st.
Annual Report
The Executive Director and the development department will complete the annual time frame with due dates from June 1st to November 30th to ensure the annual report is published annually by January 1st. The annual report will be posted on the website and mailed to stakeholders for the public to review. The public will be notified on our website annually by January 1st of the newly published annual report. The Annual Report for the 22-23 Fiscal Year has been published since the DDAP Licensing visit in March 2024.
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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 fire drill logs, the facility failed to conduct unannounced fire drills at least once a month.
Fire drill logs were submitted for January 2023, February 2023, March 2023, April 2023, May 2023, June 2023, July 2023, August 2023, September 2023, October 2023, November 2023, and January 2024. No documentation provided for December 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 13, 2023, annual inspection.
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Plan of Correction
( Fire Drills) A Fire Drill will be conducted at Sojourner House at least one time a month. Every 3 months on the overnight shift a fire drill will be completed. On the 3-11 shift every 3 months a drill will be conducted. The Support Staff supervisor will conduct all Fire Drills ensuring the fire drill report is completed documenting times, dates, and exit location and any unusual events will be documented on the form. The Sr. Clinical Manager will review fire drill reports monthly. |
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 fire drill logs, the facility failed to conduct a fire drill during sleeping hours at least every 6 months.
The fire drills were reviewed for the period of January 2023 - January 2024. The only fire drills conducted during sleeping hours in that timeframe were documented on February 9, 2023, and November 14, 2023. This period is longer than the required 6 months.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 13, 2023, annual inspection.
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Plan of Correction
A Fire Drill will be conducted at Sojourner House at least one time a month. Every 3 months on the overnight shift a fire drill will be completed. On the 3-11 shift every 3 months a drill will be conducted. The Support Staff supervisor will conduct all Fire Drills ensuring the fire drill report is completed documenting times, dates, and exit location and any unusual events will be documented on the form. The Sr. Clinical Manager will review fire drill reports monthly. |
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.
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Observations
Based on a review of administrative information, the facility failed to make the 2022-2023 annual report available to the public.
The 2022-2023 report was completed and listed required information but was not made available to the public by the time of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Executive Director and the development department will complete the annual time frame with due dates from June 1st to November 30th to ensure the annual report is published annually by January 1st. The annual report will be posted on the website and mailed to stakeholders for the public to review. The public will be notified on our website annually by January 1st of the newly published annual report. The Annual Report for the 22-23 Fiscal Year has been published since the DDAP Licensing visit in March 2024. |
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 a review of personnel records, the facility failed to provide an annual written performance evaluation which was signed by the employee in one of one applicable record.
Staff # 1 was hired on October 14, 2019. A performance evaluation was completed for 2023 but did not have the employee signature.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Department and Executive Director will ensure all employees review and sign their performance evaluations. Effective 4/15/2024, the Executive Director will ensure that the governance board adds signature lines to the annual performance evaluation to reflect both having reviewed and agreed to the information on the performance evaluation. Effective 4/15/2024, Human Resources will ensure yearly performance evaluations are completed with the employee's signature by June 30th of each fiscal year. |
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 a review of client records, the facility failed to obtain an informed and voluntary
consent from the client for the disclosure of information contained in the client record in one of seven records reviewed.
Client #2 was admitted on November 14, 2023, and was still an active client at the time of inspection. A release of information form to bill insurance for services was not documented in the record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Sr. Clinical Supervisor met with all clinical staff on 3/14/24 and conducted a review on proper documentation of voluntary consent and release of information documentation. The intake coordinator will ensure a release of information to bill insurance for services will be completed and placed in the client file. The Sr. Director will conduct weekly file audits to ensure consents are completed properly. All current and future client files will be compliant. |
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 a review of client records, the facility failed to document a purpose for disclosure on a release of information form in two of seven records reviewed.
Client #3 was admitted on November 2, 2023, and was still an active client at time of inspection. A release of information form to a physician was signed by the client on November 15, 2023, and did not indicate the purpose of disclosure.
Client #5 was admitted on December 15, 2023, and discharged on February 6, 2024. A release of information form to a case manager was signed by the client on December 21, 2023, and did not indicate the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Sr. Clinical Supervisor met with all clinical staff and conduct a review on proper documentation of voluntary consent and release of information documentation on 3/14/24.Clinical staff have been informed and instructed they must document purpose of disclosure on all releases of information. The Sr. Director will conduct weekly file audits to ensure consents are completed properly. All current and future client files will be compliant. |
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.
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Observations
Based on a review of client records, the facility failed to document a date, event, or condition upon which a consent will expire on a release of information in one of seven records reviewed.
Client #3 was admitted on November 2, 2023, and was still an active client at time of inspection. A release of information form to a physician was signed by the client on November 15, 2023, and did not indicate an expiration date, event or condition.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Sr. Clinical Supervisor met with all clinical staff and conduct a review on 3/14/24 on proper documentation of voluntary consent and release of information documentation. Clinical staff have been informed and instructed to indicate an expiration date,event or condition on all releases of information documents.The Sr. Director will conduct weekly file audits to ensure consents are completed properly. All current and future client files will be compliant. |
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 records, the facility failed to provide documentation of medication being provided as prescribed by a physician in six of six applicable records, clients #1, 2, 3, 4, 6, and 7.
Medication records reviewed failed to document the administration of the medication or the reason a medication was not administered as prescribed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
(Medication Documentation) Sojourner Houses contracted Nurse Practitioner conducted a medication documentation trainings for Sojourner House's Support Staff. The training outlined how to completed documentation on the (MAR) Medication Administration Record and Medication Log to ensure client medications and properly recorded. The training will outline key information about the individual's medication, including the medication name, dose taken, special instructions and date and times, and missed medication reason on client medical record. The Support Supervisor will conducted daily audits to ensure medication documentation is done according to Sojourner Houses medication policy and procedures. The Sr. Clinical Manager will conduct monthly audits ensuring compliance. |
709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a review of administrative information, the facility failed to inspect medication storage areas in compliance with State and Federal laws and program policy.
Facility policy and procedures indicate inspections are to be completed at the end each month.
The timeframe for review was March 2023 through February 2024. Medication storage area inspections were not provided for March 2023 through December 2023.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Medication Control Policy for medication storage. Sojourner House will complete and document a monthly storage areas inspection ensuring external and internal medications and injectable medications are stored is separately. The Recovery Support Supervisor will conduct the audits and document the inspection monthly. The Recovery Support Supervisor will remove any outdated medications from the medication room. The Sr. Clinical Manager will conduct quarterly inspections ensuring the medication control inspection and policies are being followed. |
709.32 (c) (5) LICENSURE Medication control
§ 709.32. Medication control.
(5) Security of drugs, including, but not limited to, the loss, theft or misuse of drugs.
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Observations
Based on a review of administrative information, the facility failed to provide written policy and procedures regarding security of client medications which included the loss, theft, or misuse of drugs.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Sojourner Houses medication policy and procedures regarding security of client medications which included the loss, theft, or misuse of drugs failed to be reviewed at the time of the audit. Those policy and procedures are available to be reviewed at future inspections.Sojourner Houses medication policies and procedures will be adhered to and monitored by the Support Staff Supervisor and the Sr. Clinical Manager. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
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Observations
Based on a review of administrative information, the facility failed to provide written policy and procedures for drug reactions and how they will be entered in the client record.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Sojourner Houses medication policy and procedures regarding drug reactions and how they will be entered in the client record failed to be reviewed at the time of the audit. Those policy and procedures are available to be reviewed at future inspections for drug reactions and how they are entered in the client record.Sojourner Houses medication policies and procedures will be adhered to and monitored by the Support Staff Supervisor and the Sr. Clinical Manager. |
709.51(b)(2)(iii) LICENSURE Fee Schedule
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:
(iii) Fee schedule.
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Observations
Based on a review of client records, the facility failed to document familiarization of the fee schedule to the clients during intake procedures in seven of seven records.
There was no documentation of client familiarization of the fee schedule in the record for clients #1-7.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
(Fee Schedule and Liability Forms) The Intake Coordinator will meet with all new clients to review, and sign the Fee Schedule and Liability forms during the intake orientation. The Fee Schedule and Liability Forms will be a part of the Intake Orientation Packet. The Sr. Clinical Manager will review all client files to ensure the fee schedule and liability forms have been completed. All current and future client files will be compliant. |
709.52(a)(2) LICENSURE Tx type & frequency
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:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and frequency of treatment and rehabilitation services on the treatment plan in six of seven client records.
Client #1 was admitted on September 27, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 04, 2023, with no type or frequency identified.
Client #2 was admitted on November 14, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 17, 2023, with no type or frequency identified.
Client #3 was admitted on November 2, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 21, 2023, with no type or frequency identified.
Client #4 was admitted on June 6, 2023, and was discharged on July 6, 2023. A comprehensive treatment plan was developed on June 6, 2023, with no type or frequency identified.
Client #5 was admitted on December 15, 2023, and was discharged on February 6, 2024. A comprehensive treatment plan was developed on December 19, 2023, with no type or frequency identified.
Client #7 was admitted on April 20, 2023, and was discharged on July 28, 2023. A comprehensive treatment plan was developed on April 23, 2023, with no type or frequency identified.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 13, 2023, annual inspection.
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Plan of Correction
Sojourner Houses Sr. Clinical Manager conducted a review on treatment plan documentation on 3/15/24. The Counselors will document and date the clients short and long term goals on the plan. The counselor will document frequency of individual, and group sessions on the treatment plan. The Sr. Clinical Manager will conduct weekly audits to ensure goals and interventions have projected dates on the treatment plans. |
709.52(a)(3) LICENSURE Support service type
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:
(3) Proposed type of support service.
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Observations
Based on a review of client records, the facility failed to document proposed type of support service on individual treatment plans in five of seven records.
Client #2 was admitted on November 14, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 17, 2023, and did not document any proposed type of support service.
Client #3 was admitted on November 2, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 21, 2023, and did not document any proposed type of support service.
Client #4 was admitted on June 6, 2023, and was discharged on July 6, 2023. A comprehensive treatment plan was developed on June 6, 2023, and did not document any proposed type of support service.
Client #5 was admitted on December 15, 2023, and was discharged on February 6, 2024. A comprehensive treatment plan was developed on December 19, 2023, and did not document any proposed type of support service.
Client #7 was admitted on April 20, 2023, and was discharged on July 28, 2023. A comprehensive treatment plan was developed on April 23, 2023, and did not document any proposed type of support service.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Sojourner Houses Sr. Clinical Manager conducted a review on treatment plan documentation on 3/15/24. The Counselors have been instructed to document all client support services in the intervention section of the plan. The Sr. Clinical Manager will conduct weekly audits to ensure support services are documented in the client file. |
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 review and update treatment plans at least every 30 days in three of six applicable records.
Client #1 was admitted on September 27, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on October 04, 2023. A treatment plan update was due November 4, 2023, and was not completed until November 22, 2023. Another update that was due January 22, 2024, was not completed until February 15, 2024.
Client #2 was admitted on November 14, 2023, and was still active at the time of the inspection. A comprehensive treatment plan was developed on November 17, 2023. A treatment plan update was due December 17, 2023, and was not completed until January 16, 2024. The next update was due February 16, 2024, and was not completed until February 28, 2024.
Client #5 was admitted on December 15, 2023, and was discharged on February 6, 2024. A comprehensive treatment plan was developed on December 19, 2023. A treatment plan update was due January 19, 2024, and was not completed until January 30, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Sojourner Houses Sr. Clinical Manager conducted a review on treatment plan documentation on 3/15/24. The Counselors have been informed and instructed that treatment plan review and update needs to be completed with the client every 30 days and documented in the progress note the day of the review. The Sr. Clinical Manager will conduct weekly audits to ensure the 30 day review is documented in the client chart. |
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.
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Observations
Based on a review of client records, the facility failed to document case consultations in three of six applicable records.
The facility's policy and procedure manual states a case consultation must be completed monthly.
Client #1 was admitted on September 27, 2023, and was still active at the time of the inspection. There were no case consultations notated in client #1 ' s record.
Client #2 was admitted on November 14, 2023, and was still active at the time of the inspection. There were no case consultations notated in client #2 ' s record.
Client #3 was admitted on November 2, 2023, and was still active at the time of the inspection. There were no case consultations notated in client #3 ' s record for the month of February.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Sojourner Houses Sr. Clinical Manager conducted a review on 3/15/24 The Counselors have been informed and instructed to complete a case consultation on their clients every 30 days to document the clients progress. The consultation note will have a minimum of 2 staff signatures verifying a consultation was completed on the client. The Sr. Clinical will conduct a weekly audit of the client files to ensure case consultations are completed with the needed signatures. All current and future client files will be compliant. |
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 document follow-up information in four of four discharged records.
The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 7 days.
There was no follow up information documented in client records #4, 5, 6 and 7.
Client #4 was admitted on June 6, 2023, and was discharged on July 6, 2023.
Client #5 was admitted on December 15, 2023, and was discharged on February 6, 2024.
Client #6 was admitted on April 25, 2023, and was discharged on June 22, 2023.
Client #7 was admitted on April 20, 2023, and was discharged on July 28, 2023.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility's policy and procedure manual states follow up contact is to be completed for all discharges within 7 days. Sojourner Houses Sr. Clinical Manager conducted a review on the discharge policy informing the counselors they are required to attempt to conduct and document a 7 day follow-up with all discharged clients. The Sr. Clinical Manager will conduct a weekly audit of the client files to ensure charts are compliant with Sojourner House policies and procedures on discharge follow-ups. |
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 client records, the facility failed to document that work done by the client at the project is an integral part of the treatment plan in seven of seven client records.
The facility utilizes work therapy by means of assigned chores. Work therapy was not documented on the treatment plan in client records #1, 2, 3,4, 5, 6 and 7.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the February 13, 2023, annual inspection.
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Plan of Correction
Sojourner Houses Sr. Clinical Manager conducted a review on treatment plan documentation on 3/15/24 regarding documenting the clients participation in work therapy. All clients are made in the intake orientation that work therapy is a part of programming. The counselor will update the clients required work detail on the treatment plan. The Sr. Clinical will conduct a weekly audit of the client files to ensure charts are compliant. All current and future client files will indicate work therapy is conducted. |