INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD Family 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 the facility fire drill logs from September 2023 through May 2024, the facility failed to ensure that unannounced fire drills were conducted at least once a month.
At the time of the inspection, there was no documentation that fire drills were conducted during the months of January 2024 through April 2024.
This is a repeat citation from the July 28, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A Fire Drill Monthly Schedule will be created and implemented by 6/1/2024. Staff will conduct the fire drill according to the schedule. Director will review monthly drills to ensure they are conducted. |
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 the facility fire drill logs from September 2023 through May 2024, the facility failed to maintain a written fire drill record, which is to include documenting problems encountered during the drills.
At the time of the inspection, the fire drill logs from September 2023 through December 2023 did not include documentation of any problems encountered.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Revisions were made to the Fire Drill form to include documentation of any problems on 5/30/2024. This form will be reviewed and implemented immediately. The director will ensure the proper form is completed when conducting monthly fire drills. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records and the facility policy and procedure manual, the facility failed to follow the project's written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client records reviewed.
The policy and procedure manual stated that the clients emergency contact will be contacted when the client leaves treatment against staff advice.
Client #2 was admitted on September 15, 2023, and left against staff advice on November 3, 2023. There was no documentation in the record indicating the emergency contact was notified when the client left the facility against staff advice.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The program Director will ensure upon the hiring of staff during their on-boarding process, they will be informed of the expectations when a person leaves the facility Against Facility Advice. Which includes contacting their emergency contact immediately. |
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 obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record in one of five client records reviewed.
Client #5 was admitted October 5, 2023 and was discharged November 29, 2023. There was evidence of a faxes being sent to several other treatment providers; however, there were no consent to release information forms to any of the treatment providers documented in the record prior to the disclosures of information.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Effective Immediately, Upon hire, staff will be trained in how to properly complete Consents for any individual the program will disclose information to during the participant's treatment process. Monthly chart audits will be conducted by the director to ensure the consents are properly completed. |
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 a review of client records, the facility failed to ensure a copy of a client consent form was offered to the client in one of five client records reviewed.
Client #4 was admitted October 2, 2023 and was discharged January 12, 2024. A release of information form to an external telehealth counselor was signed and dated by the client on December 19, 2023; however, there was no documentation in the record that a copy of the release form was offered to the client.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, upon hire staff will be trained to properly complete consents forms and offer the participant a copy of the completed consent. Program Director will conduct monthly chart audits to ensure that the consent properly reflects that the participant was offered a copy of the form. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to ensure all treatment and rehabilitation plans were reviewed and updates at least every thirty days in two of four applicable client records reviewed.
Client # 3 was admitted on September 19, 2023 and was discharged November 3, 2023. The individual treatment and rehabilitation plan was completed on September 19, 2023 and an update was due no later than October 19, 2023; however, the update was not completed at the time of inspection.
Client # 4 was admitted on October 2, 2023 and was discharged on January 12, 2024. The individual treatment and rehabilitation plan was completed on October 2, 2023 and an update was due no later than November 2, 2023; however, the update was not completed until November 23, 2023.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective Immediately, upon hire staff will be trained on documentation expectations and timeframes which includes the updating of rehabilitation plans every 30 days. A clinical documentation schedule will be developed and posted to include when the next plan date is due in the staff office and updated by the Program Director. A monthly chart audit will be conducted by the Program director to ensure that updates are in the charts and on time. |
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 client records, the facility failed to maintain a complete client record, which is to include the documentation of case consultation notes, in five of five client records reviewed.
Client #1 was admitted on November 17, 2023 and was discharged January 12, 2024. There was no documentation of case consultation notes during the treatment episode.
Client #2 was admitted on September 15 and was discharged November 3, 2023. There was no documentation of case consultation notes during the treatment episode.
Client #3 was admitted on September 19, 2023 and was discharged on November 3, 2023. There was no documentation of case consultation notes during the treatment episode.
Client #4 was admitted on October 2, 2023 and was discharged on January 12, 2024. There was no documentation of case consultation notes during the treatment episode.
Client #5 was admitted on October 5, 2023 and was discharged on November 29, 2023. There was no documentation of case consultation notes during the treatment episode.
This is a repeat citation from the July 28, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effectively Immediately, Upon Hire, staff will be trained in clinical documentation and expectations. Staff will be informed of a weekly Clinical Team meeting facilitated by the Program Director where a participant on their caseload will attend once a month to ensure that they receive their Case Consultation within the 90 time frame and that all member's of their team are aware of their treatment process. The Director will provide a monthly schedule of the participants expected to attend Case Consultation |