INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 15, 2021 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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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an annual written individual training plan for each employee, appropriate to that employee's skill level, with input from both the employee and the supervisor in one of five personnel records reviewed.
Employee # 2 was hired as the facility director on April 2, 2019. The individual training plan was signed by the employee on July 2, 2021, but there was no documentation verifying that the plan was developed with input from the supervisor.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #2's training plan was sent to supervisor for signature. Going forward, the facility director will be responsible for assuring that all training plans are developed and signed by the employee and the supervisor. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on the review of personnel records and staff schedules, the facility failed to ensure that CPR certification and first aid training was provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operations. The facility's hours of operation is documented as 24 hours a day, 7 days per week, and 365 days per year.
There was no CPR or first aid coverage at the facility during the following dates and times in the months of May 2021 and June 2021:
25, 2021 from 8 PM to 12 AM; May 26, 2021 from 12 AM to 8 AM and 8PM to 12 AM; May 27, 2021 from 12 AM to 8 AM; May 28, 2021 from 8 PM to 12 AM; May 29, 2021 from 12 AM to 8 AM and 8 PM to 12 AM; May 30, 2021 from 12 AM to 8 AM and 8 PM to 12 AM; and May 31, 2021 from 12 AM to 8 AM and 8PM to 12 AM.
1, 2021 from 12 AM to 8 AM and 8PM to 12 AM; June 2, 2021 from 12 AM to 8 PM; June 5, 2021 from 12 AM to 8 PM; June 8, 2021 from 8 PM to 12 AM; June 9, 2021 from 12 AM to 8 AM and 8 PM to 12 AM; June 10, 2021 from 12 AM to 8 AM; June 12, 2021 form 8 PM to 12 AM; June 13, 2021 from 12 AM to 8 AM; June 15, 2021 from 12 AM to 8 AM and 8 PM to 12 AM; June 16, 2021 from 12 AM to 8 AM; June 18, 2021 from 8 PM to 12 AM; and June 19, 2021 from 12 AM to 8 AM and 8 PM to 12 AM.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
One program nurse allowed the CPR certification to lapse, resulting in the documented shifts without CPR coverage. That certification has been updated, so all shifts have a staff member certified in CPR.
Going forward, the Nurse Manager will keep a list of certification expiration dates to assure that all nurses maintain updated CPR certifications. This will assure that all shifts will have a CPR-certified staff member on site. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of training during the facility's July 1, 2019 through June 30, 2020 training year.
Employee #1 was hired as the Project Director on February 28, 2018. The personnel record documented 0 hours of training during the reviewed training year.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The project director did not have training hours during the noted period. The project director did have the appropriate training hours during the past training year and will be responsible for assuring enough hours in the coming year and ongoing. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually during the facility's July 1, 2019 through June 30, 2020 training year in one of two applicable personnel record reviewed.
Employee # 6 was hired as a counselor on April 2, 2019. The personnel record documented 9 hours of training received during the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #6 did not have enough training hours during the noted period, though had more than twice the number of required hours during the most recent training year. Going forward, the facility director will assure that each staff member has sufficient training to meet licensing requirements and program needs. This will be accomplished through the annual training plan, regular supervision and a training calendar. |
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's June 2020 through June 2021 fire drill log, the facility failed to ensure that their written fire drill log included the amount of time it took for evacuation, the exit route used and whether the fire alarm or smoke detector was operative.
The June 2021 drill log did not document which exit route was used. The October 2020 drill log did not document the time of the drill, the amount of time it took for evacuation and which exit route was used. The April 2021, February 2021, November 2020, September 2020 and July 2020 drill logs did not document whether the fire alarm or smoke detector was operative at the time of the drills.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drill documentation has been reviewed with the staff member responsible for it. Going forward, the facility director will review the fire drill log each month to assure that all pieces of information are included correctly. |
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 complete an informed and voluntary consent to release information form prior to the disclosure of information in three of seven client records reviewed.
Client # 4 was admitted on August 20, 2020 and was discharged on March 17, 2021. There was evidence of a disclosure to another treatment provider on March 22, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 5 was admitted on December 17, 2020 and was discharged on July 2, 2021. There was evidence of a disclosure to another treatment provider on July 8, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
Client # 7 was admitted on July 2, 2020 and was discharged on April 30, 2021. There was evidence of a disclosure to another treatment provider on May 14, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
This is a repeat citation from the March 15, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Before discharge, each resident will be asked to complete and sign a release of information form for the providers to whom he or she has been referred upon discharge from the program.
This will be the responsibility of the Resource Coordinator and reviewed by the facility director.
If the resident chooses not to sign a release, the program will not contact the outside provider after the resident's discharge.
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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 review and update treatment and rehabilitation plans at least every thirty days in one of three applicable client records reviewed.
Client # 5 was admitted on December 17, 2020 and was discharged on July 2, 2021. A treatment plan update was completed on March 6, 2021 and an update was due no later than April 6, 2021; however, the update was not completed until May 5, 2021.
This is a repeat citation from the March 15, 2021 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Client #5 changed therapists around the time of the late treatment plan and we apologize for its lateness.
Going forward, we have instituted a process whereby therapists audit each other's charts, in addition to audits conducted by the facility director, to assure that all treatment plans are completed within the appropriate timeframes. |