INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 2, 2023 through October 3, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Peace and Harmony 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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704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure that a counselor assistant satisfactorily completed the required educational and experiential qualifications prior to being promoted to the position of counselor in one of one applicable personnel records reviewed. Employee # 6 was hired as an associate's-level counselor assistant on March 28, 2022 and was promoted to a counselor on November 1, 2022. At the time of the promotion, the employee only had one year of documented clinical experience in a health or human service agency; however, two years of clinical experience is required to qualify as a counselor. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, Peace and Harmony House will not hire counselor assistants moving forward. We will only hire staff that meet the qualifications of a counselor. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 the facility's October 2022 through September 2023 fire drill log, the facility failed to ensure that all their written fire drill logs included the date of the fire drill. The October 2022 and November 2022 fire drill logs were missing the date of the fire drill. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately Facility Director will make sure fire drill logs include the dates of the fire drill as they happen. Compliance Officer will audit the logs by the 25th of the month to make sure that the fire drills have taken place and it is documented correctly in the log. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in four of fourteen applicable client records reviewed. Client # 1 was admitted to the partial hospitalization activity on December 6, 2022 and was discharged on January 7, 2023. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 4 was admitted to the partial hospitalization activity on February 2, 2023 and was discharged on February 24, 2023. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. Client # 8 was admitted to the outpatient activity on March 6, 2023 and was still active at the time of the inspection. The release of information form to the funding source was signed by the client on July 11, 2022 and it expired on July 12, 2023. There was evidence of disclosures to the funding source after the release of information form expired; however, there was no updated consent to release information form signed by the client documented in the record prior to any of the disclosures after July 12, 2023. Client # 9 was admitted to the outpatient activity on February 27, 2023 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately Case Manager was hired to complete all intakes for Peace and Harmony House. Case Manager and Executive Assistant reviewed the intake packet and made sure all documents/consents needed are in the intake packet. Case Manager will also have blank consents for additional external collateral. Clinical Supervisor/Project Director will check all intake packets upon completion to make sure all consents have been signed. Billing Specialist will email counselor 2 weeks in advance to update yearly consent forms. The ROI's of active clients will be completed the next appointment upon audit and If the clients have been discharged since the inspection, and the ROIs can't be completed we will not disclose any information to those entities. |
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 a review of client records, the facility failed to document the name of the person, agency or organization to whom the disclosure is made on a consent to release information form in one of fourteen client records reviewed. Client # 1 was admitted to the partial hospitalization activity on December 6, 2022 and was discharged on January 7, 2023. The release of information form to the emergency contact was signed and dated by the client and witness on December 6, 2022; however, the form failed to document the name of the person, agency or organization to whom the disclosure would be made. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, If a client does not have an emergency contact there will not be a ROI on file. Peace and Harmony House have hired a case manager who has been trained efficiently on all consent forms. Case Manager will have the name of the person/agency/organization to release info to on the consent form. The clinical director and project director will be auditing all intakes and new ROI's to make sure they are done correctly. |
709.82(a)(2) LICENSURE Treatment and rehabilitation services
709.82. 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 individual treatment and rehabilitation plan in five of seven client records reviewed.Client # 1 was admitted to the partial hospitalization activity on December 6, 2022 and was discharged on January 7, 2023. The individual treatment and rehabilitation plan was completed on December 21, 2022; however, it failed to document the type and frequency of treatment services.Client # 2 was admitted to the partial hospitalization activity on December 22, 2022 and was discharged on March 16, 2023. The individual treatment and rehabilitation plan was completed on December 22, 2022; however, it failed to document the frequency of treatment services.Client # 4 was admitted to the partial hospitalization activity on February 2, 2023 and was discharged on February 24, 2023. The individual treatment and rehabilitation plan was completed on February 2, 2022; however, it failed to document the type of treatment services.Client # 5 was admitted to the partial hospitalization activity on March 6, 2023 and was discharged on March 31, 2023. The individual treatment and rehabilitation plan was completed on March 6, 2022; however, it failed to document the type of treatment services.Client # 6 was admitted to the partial hospitalization activity on November 29, 2022 and was discharged on February 10, 2023. The individual treatment and rehabilitation plan was completed on December 2, 2022; however, it failed to document the type and frequency of treatment services.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, All clinicians have been trained on type and frequency with treatment plans by clinical supervisor. Clinical Supervisor are auditing all treatment plans until she feels as though the clinician is efficiently preparing them. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. 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 individual treatment and rehabilitation plan in seven of seven applicable client records reviewed.The individual treatment and rehabilitation plan in each client record reviewed did not document the type and frequency of treatment and rehabilitation services. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, All clinicians have been trained on type and frequency with treatment plans by clinical supervisor. Clinical Supervisor are auditing all treatment plans until she feels as though the clinician is efficiently preparing them. All types and frequency of rehabilitation services will be on the initial treatment plan and master treatment plan. Clinical Supervisor will make sure all clinicians update treatment plans depending on the level of care change with frequency and type of treatment. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every sixty days in three of seven applicable client records reviewed. Client # 8 was admitted to the outpatient activity on March 6, 2023 and was still active at the time of the inspection. A treatment plan update was completed on July 7, 2023 and an update was due no later than September 7, 2023; however, the update was not completed at the time of the inspection. Client # 9 was admitted to the outpatient activity on February 27, 2023 and was still active at the time of the inspection. A treatment plan update was completed on May 9, 2023 and an update was due no later than July 9, 2023; however, the update was not completed at the time of the inspection. Client # 10 was admitted to the outpatient activity on April 12, 2023 and was discharged on September 22, 2023. update was completed on July 12, 2023 and another update was due no later than September 12, 2023; however, the update was not completed at the time of the inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, Clinical Supervisor has made sure all active clients treatment plans have been updated according. If the clients have been discharged since the inspection,the treatment plans can't be updated at this time. Clinical Supervisor implemented all clinicians give her a calendar monthly of all updated treatment plan due dates. Clinical Supervisor will review that all updated treatment plan is due on the designated date. |
709.93(a)(9) LICENSURE Client records
709.93. 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 document an aftercare plan in one of two applicable client records reviewed.Client # 14 was admitted to the outpatient activity on March 8, 2023 and was discharged on July 19, 2023. The client record did not document an aftercare plan as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately Clinical Supervisor has a discharge checklist that all clinicians have to follow in which it states an aftercare Plan have to be created before discharge. Clinical Supervisor/Facility Director have implemented a Discharge Audit Log to check and make sure all charts are complete with documentation upon discharge. |