INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 2017 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, Resources for Human Development Inc. Morris 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in 2 of 7 personnel records reviewed.
Employee #6 was hired as a recovery specialist on 2/27/15. Employee #6 was due to complete the required HIV/AIDS and TB/STD trainings no later than 2/27/17. However, the record contained no documentation that the employee completed the HIV/AIDS training or the TB/STD training at the time of inspection.
Employee #7 was hired as a recovery specialist on 12/2/14. Employee #7 was due to complete the required TB/STD training no later than 12/2/16. However, the record contained no documentation that the employee completed the TB/STD training at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with Employee #6 on 7/26/17 to review training requirements. The Employee has registered for 6 hours of HIV/AIDS Trainings using Department Approved Curriculum, to be completed on September 6, 1017. The employee has also registered for 4 hours of TB/STD training, to be completed on September 25th, 2017. The Director met with employee #7 on 7/27/2017. The Employee will be registered to complete four hours of TB/STD training on September 25, 2017. The Director and Office Manager will conduct quarterly reviews of all employee training plans and training logs, to ensure that all staff are in compliance with regulatory timeframes. The Director will be responsible for ensuring that the corrective action is implemented. |
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 7 client records, the facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in 4 client records.
Client #2 was admitted on 1/29/17 and was discharged on 6/5/17. The client record contained documentation of correspondence with the funding source on 3/1/17 and 5/15/17, which disclosed the client ' s specific psychotropic medications. Additionally, the record contained documentation of correspondence with the funding source on 5/8/17, 4/26/17, and 3/27/17, which disclosed details of recent relapses including specific substances and quantities used.
Client #3 was admitted on 10/4/16 and was discharged on 3/1/17. The client record contained documentation of correspondence with the funding source on 11/18/16 and 10/26/16, which disclosed the client's specific psychotropic medications.
Client #5 was admitted on 5/24/17 and was an active client at the time of inspection. The client record contained documentation of correspondence with the funding source on 6/23/17, which disclosed the client's specific psychotropic medications.
Client #6 was admitted on 3/10/17 and was an active client at the time of inspection. The client record contained documentation of correspondence with the funding source on 4/7/17, which disclosed the client's specific psychotropic medications. Additionally, the record contained documentation of correspondence with the funding source on 5/15/17 and 7/10/17, which disclosed details of recent relapses including specific substances and quantities used.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The director will meet with the clinical team on 8/9/2017 to review PA Code 255.5 (b). Additionally, Director will sit in on 1 review between the clinical team and the funding sources monthly for the next 4 months to ensure that all disclosures are within the limits of the code. |
709.30 (1) 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.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
Based on a review of client records, the facility failed to include documentation that the facility does not discriminate in the provision of services based on marital status, ethnicity, and sexual orientation on the written acknowledgement form that the clients signed in all 7 client records reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RHD Morris Home Program Intake Packet, specifically the Civil Rights Compliance form, will be updated by the program, with RHD final approval, to include documentation that RHD Morris Home does not discriminate in the provision of services based on marital status, ethnicity and sexual orientation. This will occur by 8/15/2017. New admissions beginning on 8/15/2017 will sign the updated and RHD approved Civil Rights Compliance Form as part of the intake process. Current clients will review and sign the updated RHD approved Civil Right Compliance Form on 8/15/2017. The Director will be responsible for ensuring that the revised forms are utilized. |
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 7 client records, the facility failed to provide a complete client record in client records #'s 1, 2, 3, 4, 6, and 7.
Client #1 was admitted on 3/10/17 and was discharged on 4/12/17. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #2 was admitted on 1/29/17 and was discharged on 6/5/17. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #3 was admitted on 10/4/16 and was discharged on 3/1/17. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #4 was admitted on 11/28/16 and was discharged on 2/4/17. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #6 was admitted on 3/10/17 and was an active client at the time of inspection. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan as of the date of the inspection.
Client #7 was admitted on 6/22/17 and was an active client at the time of inspection. The client record did not contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation 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
The Director met with the Morris Home clinical team on 7/20/2017 to discuss the regulation stating that client records contain verification that work done by the client at the project is an integral part of the treatment and rehabilitation plan. On 7/20/2017, the Morris Home Treatment Plan format was changed to include verification about work done by the client. As of 7/20/2017, all Morris Home treatment plans will contain this language. Director will be responsible for monthly review of treatment plans to ensure they are in compliance with this regulation. |