INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 10, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection Resources for Human Development 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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709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
The facility failed to document that the project director had prepared, annually updated and signed the facility's written manual, which delineates the project policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A document has been added into our current policy and procedure manual that reflects the project directors annual review (prepare and update) along with a signature field to reflect the date on which the director has completed the annual review. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
The facility failed to ensure that the personnel records contained documentation of an annual written individual performance evaluation in one of four employee records reviewed.
Employee # 2 was hired as the facility director on September 8, 2017. There was no documentation of an annual written individual performance evaluation completed for the review year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2 will receive a written annual evaluation no later than August 15, 2019. Facility Director will remind supervisor to complete annual evaluation each year in order to comply with state regulations. |
709.34 (b) (3) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
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Observations
The facility failed to develop policy and procedures for the implementation of a timely and appropriate corrective action plan, when indicated, with regards to an unusual incident.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility has modified unusual incident policy to reflect the implementation of a timely and appropriate corrective action plan. Modifications to policy listed below:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
Director will work with Divisional Leadership and/or National Incident Manager to implement a Corrective Action Plan at the completion of review, or investigation when needed.
(4) Ongoing monitoring of the corrective action plan
During Corrective Action Plan Development, a plan for duration and frequency of ongoing monitoring will be established, and Director, Divisional Leadership, and National Incident Manager will convene as necessary to review.
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709.34 (b) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(b) Policies and procedures must include the following:
(4) Ongoing monitoring of the corrective action plan.
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Observations
The facility failed to develop policy and procedures for the ongoing monitoring of the corrective action plan, with regards to an unusual incident.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Facility has revised unusual incident policy to reflect procedures for the ongoing monitoring of the corrective action plan. Modifications to policy listed below:
(3) Implementation of a timely and appropriate corrective action plan, when indicated.
Director will work with Divisional Leadership and/or National Incident Manager to implement a Corrective Action Plan at the completion of review, or investigation when needed.
(4) Ongoing monitoring of the corrective action plan
During Corrective Action Plan Development, a plan for duration and frequency of ongoing monitoring will be established, and Director, Divisional Leadership, and National Incident Manager will convene as necessary to review.
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709.43(e) LICENSURE Consent to TX
709.43. Client management.
(e) A consent to treatment form should be completed and signed by the client and intake worker at intake.
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Observations
The facility failed to document a signed consent to treat form in all seven client records reviewed in the Intake, Evaluation and Referral activity.
The findings were discussed with facility staff during the licensing process
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Plan of Correction
Facility director has communicated to all clinicians providing Intake, Evaluation, and Referral activities to begin including consent to treat forms effective immediately in all client charts. Corrective action has been implemented as of 7/16/19.
This document title will be added to internal chart audit tool used to monitor IER charts. IER charts are randomly audited on a monthly basis. Unit Director and/or designated supervisor of these charts will randomly audit charts to ensure these documents are included in client files. |