INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 24, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection Harwood 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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705.10 (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 facility fire drill records from December 2016 to December 2017, the facility failed to document that fire drills during sleeping hours were conducted at least every 6 months as there were no fire drills conducted during sleeping hours until October 2017. Additionally, the facility failed to conduct unannounced fire drills at least once a month as there was no fire drill documented for the month of January 2017.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff on duty is responsible for conducting a fire drill monthly and during sleeping hours and is responsible for the proper documentation.
The Clinical Supervisor is responsible for ensuring that safe fire drills and conducted monthly and that fire drills during sleeping hours are completed every six months.
The Program Director is responsible for the overall compliance.
Staff on duty working sleep hours will be notified by documentation in staff log on 1/26 of conducting sleep hour drills between the hours of 10:30pm-7:am. All staff will be re-trained in fire drill compliance at staff meeting (clinical on 1/28/18 and program workers on 2/19/18 |
709.30 (2) 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.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of 7 client records, all 7 client records reviewed lacked documentation verifying written acknowledgement by clients that they had been notified of each of the client rights, including the project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the program director and clinical supervisor that the client rights written acknowledgement form include that Harwood House will not discriminate in the provision of services on the basis of age, race, creed, sex ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
The program director added the discrimination statement to the client rights form on 1/25/18.
All staff will be notified of the statement being added to the client rights form during clinical staff meeting on 1/29/18 and program workers meeting on 2/19/18. The new client rights acknowledge form will be place in the staff log on 1/25/18 for all staff to read.
The clinical team will review with active clients the acknowledge of client rights form and have the client sign the updated form for the client record by 2/2/18.
The program director is responsible for overall compliance. |
709.34 (c) (1) 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:
(1) Physical or sexual assault by staff or a client.
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Observations
Based on the review of the facility's unusual incident reports, the facility failed to notify the Department within 3 business days following the unusual incidents below:
The incident dates and incident reasons are:
July 1, 2017 - ambulance and police presence requested
May 25, 2017- police presence requested
February 24, 2017- fire department presence
February 7, 2017- fire department presence
These findings were reviewed with project and facility staff during the licensing process.
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Plan of Correction
It is the responsibility of the staff on duty to follow policy and procedure 709.34 on the reporting of unusual incidents. According to this policy staff will report an unusual incident to the clinical supervisor and a report will be reported within 2 business days to DDAP and other required sources by the clinical supervisor of a designee.
The incidents within this citation will be reported to DDAP by 2/2/18. This is the responsibility of the clinical supervisor
It is the responsibility of the clinical supervisor and program worker supervisor to ensure that all staff have reviewed the policy and procedure during the clinical staff meeting on 1/29/18 and during the program worker meeting on 2/19/18.
It is the responsibility of program director to post the unusual incident policy in the program worker office and front office and to place the policy in the staff log book on 1/25/18. |