INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 14, 2025, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resurrection 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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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 seven client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information in one of the seven records reviewed.
Client #5 was admitted on November 1, 2024, and was still active at the time of the inspection. There was documentation that information was disclosed to an emergency contact on November 1, 2024, however the record did not contain documentation of an informed and voluntary consent from the client for the disclosure of information.
This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Client #5's emergency contact release was incomplete. All information releases will have all the fields required to be completed before they permit signatures. The electronic medical record has implemented this as of 03/25/2025. All staff have been informed of this change.
It is the responsibility of the Chief Clinical Officer to ensure that the plan of corrections is implemented by the staff.
Client #5, completed a new form on 3/24/25 with all fields completed, and revocation statement was implemented on new form. |
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 obtain an informed and voluntary consent from the client to for the disclosure of information contained in the client record to include the name of the person, agency or organization in two out of seven records reviewed.
Client #6 was admitted on November 01, 2024, and discharged on February 3, 2025. A consent to release information form was signed and dated by the client, on November 01, 2024; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.
Client #7 was admitted on November 08, 2024, and discharged on January 27, 2025. A consent to release information form was signed and dated by the client, on November 08, 2024; however, it did not indicate the name of the person, agency or organization to whom disclosure may be made.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #6 and #7 had a release of information that was incomplete. All releases of information will have all the fields required to be completed before they permit signatures. The electronic medical record has implemented this as of 03/25/2025. All staff have been informed of this change.
The Chief Clinical Officer, is responsible to ensure that all staff are informed and trained on the updated procedure in the medical record and that the plan of correction is implemented. |
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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record which included the purpose of the disclosure in six out of seven records reviewed.
Client #1 was admitted on October 30, 2024, and discharged on March 12, 2025. An informed and voluntary consent from the client for the disclosure of information to a hospital, signed and dated October 30, 2024, did not include the purpose of the disclosure.
Client #2 was admitted on October 30, 2024, and discharged on December 18, 2024. An informed and voluntary consent from the client for the disclosure of information to the funding source, signed and dated October 30, 2024, did not include the purpose of disclosure.
Client #3 was admitted on November 27, 2024, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to the funding source and the local hospital, signed and dated November 11, 2024, did not include the purpose of disclosure.
Client #4 was admitted on October 30, 2024, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information to the funding source and the emergency contact, signed and dated October 30, 2024, did not include the purpose of disclosure.
Client #6 was admitted on November 1, 2024, and discharged on February 3, 2025. An informed and voluntary consent from the client for the disclosure of information to the emergency contact, funding source, and transportation agency, signed and dated November 1, 2024, did not include the purpose of disclosure.
Client #7 was admitted on November 8, 2024, and discharged on January 27, 2025. An informed and voluntary consent from the client for the disclosure of information to the funding source, signed and dated November 8, 2024, did not include the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Clients #1, #2, #3, #4, #6 and #7 had a release of information that was incomplete (purpose for release). All releases of information will have the purpose of disclosure field required to be completed before they permit signatures. The electronic medical record has implemented this as of 03/25/2025. All staff have been informed of this change. The Chief Clinical Officer is responsible to ensure the plan of correction is implemented.
All incomplete forms of active client records for client #3 & client #4 have been revoked and new forms have been completed and signed. The Chief Clinical Officer is responsible to ensure that all staff are informed and implemented this plan of correction. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to obtain informed and voluntary consent forms from the client which included the dated signature of the client in two out of seven records reviewed.
Client #1 was admitted on October 30, 2024, and discharged on March 12, 2025. An informed and voluntary consent form from the client for the disclosure of information contained in the client record dated October 30, 2024, for a funding source, and emergency contact did not include the dated signature of the client. The facility confirmed disclosure had occurred.
Client #3 was admitted on November 27, 2024, and was still active at the time of the inspection. An informed and voluntary consent from the client for the disclosure of information contained in the client record dated November 27, 2024, for outreach services did not include the dated signature of the client.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Client #1 and client #3 did not sign a release of information form. As of 3/25/2025, our electronic medical record requires a client signature to be completed before permitting staff signatures. This will prevent consents being completed by staff without the client's signature. All staff have been informed of this change and the Chief Clinical Officer is responsible for ensuring that the plan of correction is implemented. Client #3 incomplete forms have been revoked and new forms have been completed and signed. |
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 the client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the clients that recorded the date, event, or condition upon which the consent will expire in seven out of seven records reviewed.
Client #1 was admitted on October 30, 2024, and discharged on March 12, 2025. A release of information form dated October 30, 2024, to a funding source, hospital, emergency contact, and a clinic, did not document the date, event or condition upon which the consent would expire.
Client #2 was admitted on October 30, 2024, and discharged on December 18, 2024. A release of information form dated October 30, 2024, to a funding source, and the hospital, did not document the date, event or condition upon which the consent would expire.
Client #3 was admitted on November 27, 2024, and was still active at the time of the inspection. A release of information form dated November 27, 2024, to a funding source, hospital, emergency contact, county offices, outreach services and a clinic, did not document the date, event or condition upon which the consent would expire.
Client #4 was admitted on October 30, 2024, and was still active at the time of the inspection. A release of information form dated October 30, 2024, to a funding source, hospital, emergency contact, probation and the public defender, did not document the date, event or condition upon which the consent would expire.
Client #5 was admitted on November 1, 2024 and was still active at the time of the inspection. A release of information form dated November 11, 2024, to the hospital, funding source and clinic, did not document the date, event or condition upon which the consent would expire. In addition, a release of information form dated November 2, 2024, to the county courthouse did not document the date, event or condition upon which the consent would expire.
Client #6 was admitted on November 1, 2024, and discharged on February 3, 2025. A release of information form dated November 1, 2024, to the funding source, emergency contact, did not document the date, event or condition upon which the consent would expire. In addition, a release of information form dated December 20, 2024, to outreach services did not document the date, event or condition upon which the consent would expire.
Client #7 was admitted on November 8, 2024, and discharged on January 27, 2025. A release of information form dated November 8, 2024, to the funding source, emergency contact, county probation, and hospital, did not document the date, event or condition upon which the consent would expire. In addition, a release of information form dated December 24, 2024, to a lawyer, did not document the date, event or condition upon which the consent would expire. Another release of information form dated December 27, 2024, to outreach services did not document the date, event or condition upon which the consent would expire.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At the top of every release of information it has the date and time that the release expires. All consents have been updated in the EMR system with a revocation statement on 3/21/2025.
The currently active clients at time of inspection had old release forms revoked and new ones signed and dated with revocation statement on the new form. Some forms were resigned on 3/21/2025 and others on 3/25/2025.
The Chief Clinical Officer is responsible for ensuring that this plan of correction was implemented by staff. |
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 medication administration records provided by the facility, the facility failed to document medication errors in the client record in six out of seven records reviewed.
Client #1 was admitted on October 30, 2024, and discharged on March 12, 2025. Client #1 was prescribed Amoxixillin 500 mg tablets three times daily on March 1, 2024. There was no documentation of the medication being administered three times a day or the reason not administered on March 2-3,5,8-12, 2025. There was a prescription for Prazosin 1mg capsule one time daily in the evening starting on October 30, 2024. There was no documentation of the medication being administered one time a day or the reason not administered on December 11-12, 19, 24, 28,2024 and March 2-12, 2025.
Client #2 was admitted on October 30, 2024, and discharged on December 18, 2024. Client #2 was prescribed Buspirone HCL 7.5mg one tab two times daily on October 30, 2024. There was no documentation of the medication being administered two times a day or the reason not administered on November 3, 8-9, 14, 20-21,23, 28, 2024.
Client #3 was admitted on November 27, 2024, and was still active at the time of the inspection. Client #3 was prescribed Hydrochlorotiazide 12.5 mg tablet one time a day on November 27, 2024. There is no documentation of the medication being administered one time a day or the reason not administered on December 23, 25-26, 2024, and January 5, 2025. There was a prescription started for Metroprolol 100mg in the AM on November 27, 2024. There was no documentation of the medication being administered in the AM or the reason not administered on February 11, 23, 28 2025. There was a prescription for Lisinpril 20 mg tablet one time a day started on November 27, 2024. There was no documentation of the medication being administered one time a day or the reason not administered on January 4-5, 12, 2025. There was also a prescription for Amlodpine 5mg tablet every twelve hours. There was no documentation of the medication being administered every 12 hours or the reason not administered on December 17-18, 24-26, 2024 and January 2, 5, 12, 23, 2025. There was a prescription for Buprenorp-Nalox 8-2 mg film one time daily. There was no documentation of the medication being administered one time a day or the reason not administered on December 4-6, 10-12, 16-18, 21, 23-24, 26, 30-31, 2024 and February 3-4, 10-11, 17-18, 20-23, 25-28, 2025.
Client #4 was admitted on October 30, 2024, and was still active at the time of the inspection. Client #4 was prescribed Robaxin 500 mg tablet one time daily on October 30, 2024. There is no documentation of the medication being administered one time a day or the reason not administered on December 8-10, 2024.
Client #5 was admitted on November 1, 2024 and was still active at the time of the inspection. There was a prescription for Lisinopril 20 mg tablet in the AM on November 1, 2024. There was no documentation of the medication administered in the AM or the reason not administered on March 4, 8-10, 2025. There was a prescription for Metoprolol 25mg tablet one time daily in the AM. There was no documentation the medication was administered one time a day in the AM or the reason not administered on March 4, 8-10, 2025. There was a prescription for Amlodpine 10 mg one time a day in the AM. There was no documentation of the medication being administered one time a day in the AM or the reason not being administered on March 4, 8-10, 2025. There was a prescription for Trelegy 100 mcg one time a day in the AM. There was no documentation of the medication being administered one time a day in the AM or the reason not administered on March 4, 8-13, 2025.
Client #7 was admitted on November 8, 2024, and discharged on January 27, 2025. There was a prescription for Doxepin 100 mg tablet one time a day. There was no documentation of the medication administered one time a day or the reason not administered on December 10, 25-26, 31, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A "Missed Medication" log has been implemented as proof of documentation for any missed medication and/or refusal of medication. This has been implemented as of Tuesday, March 25, 2025. The Chief Clinical Officer is responsible to ensure that the plan of correction has been implemented. |