INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 11-13, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Britelife Recovery at Hanover LLC 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a reivew of the facility's Staffing Requirements Facility Summary Report the facility failed to provide documentation of a full-time clinical supervisor for every eight full-time counselors.The Staffing Requirements Facilities Summary Reports dated December 15, 2023 documented a total of 8.75 full-time counselors employed by the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A full-time Clinical Supervisor (Clinical Director) was hired and started working on 1/3/2024 to supervise the Clinical staff on-site. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 fire drill logs from December 2022 - November 2023, the facility failed to document exit routes being utilized during evacuations.
In addition, the fire drill log for August 26, 2023 did not document whether or not the fire alarm was functioning properly.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Fire Drill Log form was updated to include documentation of exit route being utilized during evacuation. A training with the Operations team occurred on 12/13/2023 to review the changes in the form as well as including documentation of the operation or nonoperation of fire alarm functions. The Director of Operations will continue retraining the Operations team on the use of the Fire Drill Form on a quarterly basis. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs from December 2022- November 2023, the facility failed to document alternative exit routes being utilized during evacuations.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Facility Fire Drill Log form was updated to include documentation of alternative exit routes being utilized during evacuation. A training with the Operations team occurred on 12/13/2023 to review the changes in the form. The Director of Operations will continue retraining the Operations team on the use of the Fire Drill Form on a quarterly basis. |
709.28 (c) (2) 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:
(2) Specific information disclosed.
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Observations
Based on the review of detox client records, the facility failed to document an informed and voluntary consent to release information, to include the specific information disclosed, in one out of seven client records reviewed.
Client #7 was admitted on December 1, 2023, and was discharged on December 3, 2023. The client record contained a consent form, dated December 3, 2023, for an insurance provider that was signed by the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
An all-staff training was conducted on 12/20/2023 by the Executive Director to review the process for completion of the Consent to Release Information and all required steps in the process of documentation. Training also included the proper process on including specific information to be disclosed. The Clinical Director will review and retrain staff on this process on an annual basis. |
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 the review of detox client records, the facility failed to document an informed and voluntary consent to release information, to include the purpose of the disclosure, in one out of seven client records reviewed.
Client #7 was admitted on December 1, 2023, and was discharged on December 3, 2023. The client record contained a consent form, dated December 3, 2023, for an insurance provider that was signed by the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Plan of Correction:
An all-staff training was conducted on 12/20/2023 by the Executive Director to review the process for completion of the Consent to Release Information and all required steps in the process of documentation. Training also included the required process of identifying a purpose of the disclosure of information. The Clinical Director will review and retrain staff on this process on an annual basis. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on the review of detox client records, the facility failed to document an informed and voluntary consent to release information, to include documentation that a copy of a client consent was offered to the client, in three out of seven client records reviewed.
Client #2 was admitted on December 8, 2023, and was still active at the time of the inspection. The client record contained a consent form, dated December 10, 2023, for a pharmacy that didn't include the required information. Additionally, this client record contained a consent form, dated December 10, 2023, for a parent didn't include the required information.
Client #4 was admitted on December 10, 2023, and was still active at the time of the inspection. This client record contained a consent form, dated December 10, 2023, for a pharmacy didn't include the required information.
Client #7 was admitted on December 1, 2023, and was discharged on December 3, 2023. The client record contained a consent form, dated December 3, 2023, for an insurance provider didn't include the required information. Additionally, this client record contained a consent form, dated December 3, 2023, for clergy didn't include the required information.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
An all-staff training was conducted on 12/20/2023 by the Executive Director to review the process for completion of the Consent to Release Information and all required steps in the process of documentation. Training also included the required process of offering a copy of the consent to the client and documentation of whether they accepted or declined. The Clinical Director will review and retrain staff on this process on an annual basis. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on a review the facility's incident log, the facility failed to inform the Department of an unusual incident within the required three days. On October 30, 2023, an ambulance was required at the facility to assist an injured client. There was no documentation to verify this had been reported to the Department.
This finding was reviewed with project and facility staff during the licensing inspection.
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Plan of Correction
Executive Director completed a retraining with the Director of Nursing to review company and DDAP policy on reporting of unusual incidents. Moving forward, the Executive Director will be reviewing the procedure with the Director of Nursing when an unusual incident occurs to ensure that reporting is completed. |
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 residential client records, the facility failed to document proposed type of support service on individual treatment plans in seven out of seven records reviewed.
Client #8 was admitted on November 22, 2023, and was still active at the time of the inspection.
Client #9 was admitted on December 3, 2023, and was still active at the time of the inspection.
Client #10 was admitted on November 30, 2023, and was still active at the time of the inspection.
Client #11 was admitted on December 8, 2023, and was still active at the time of the inspection.
Client #12 was admitted on admitted on September 26, 2023, and discharged on October 18, 2023.
Client #13 was admitted on admitted on August 24, 2023, and discharged on September 19, 2023.
Client #14 was admitted on admitted on June 15, 2023 and discharged on July 5, 2023.
This finding was reviewed with facility staff during the licensing inspection
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Plan of Correction
Chief Clinical Officer will be updating the treatment plan template in the EMR to add a section that reflects proposed support services. Chief Clinical Officer will be training Clinical staff on the new template on 1/8/2024. Clinical Director will be performing ongoing chart audits for monitoring compliance on a monthly basis. |
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 residential client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in seven out of seven applicable records reviewed. The facility's policy and procedure manual states " multidisciplinary meeting notes are completed at least once weekly. "
Client #8 was admitted on November 22, 2023, and was still active at the time of the inspection. There were no case consultations documented in the client record.
Client #9 was admitted on December 3, 2023, and was still active at the time of the inspection. There were no case consultations documented in the client record.
Client #10 was admitted on November 30, 2023, and was still active at the time of the inspection. There was one case consultation documented in the client record on December 1, 2023
Client #11 was admitted on December 8, 2023, and was still active at the time of the inspection. There were no case consultations documented in the client record.
Client #12 was admitted on admitted on September 26, 2023, and discharged on October 18, 2023. There were no case consultations documented in the client record.
Client #13 was admitted on admitted on August 24, 2023, and discharged on September 19, 2023. There were no case consultations documented in the client record.
Client #14 was admitted on admitted on June 15, 2023 and discharged on July 5, 2023. There were no case consultations documented in the client record.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director updated the policy and procedures to reflect the change made from weekly documentation to monthly documentation. Staff was informed of the policy change on 1/3/2024 by Executive Director.
Clinical Director will be completing chart audits to monitor compliance on a monthly basis. |
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 residential client records, the facility failed to provide a complete client record, which is to include follow-up information within seven days of discharge, as per the facility's policy, in two of three applicable client record.
Client #12 was admitted on September 26, 2023 and was discharged on October 18, 2023. There was no documentation of a follow-up contact in this client record.
Client #14 was admitted on June 15, 2023, and was discharged on July 5, 2023. There was no documentation of a follow-up contact in this client record.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Executive Director and Director of Client Care developed a new standard for Case Management staff to run a report on previous week discharges in order to track the need for follow-up calls. Director of Client Care will be running monthly reports to audit the process. Executive Director and Director of Client Care will be facilitating a training with Case Management staff on 1/8/2024 to review the policy, process and standard work. |