INITIAL COMMENTS
|
This report is a result of an on-site licensing inspection conducted on June 5-6, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing 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:
|
Plan of Correction
|
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on the review of personnel records, the facility failed to document that fire extinguisher training was provided upon employment in three out of four personnel records.
The findings include:
On June 5, 2012, four personnel records were reviewed for documentation of fire extinguisher training. The facility did not document that fire extinguisher training was provided upon employment in personnel records # 4, 5 and 6.
Personnel # 4 was hired on 11/21/11, but verification of this training was not documented until 5/23/12.
Personnel # 5 was hired on 4/11/12, but verification of this training was not documented until 5/9/12.
Personnel # 6 was hired on 4/28/12, but verification of this training was not documented until 5/9/12.
An interview with the facility director on June 5, 2012 confirmed the findings.
|
Plan of Correction
Effective August 1, 2012 the Director will ensure that all staff upon hire will attend fire extinguisher training. Director will monitor for on-going compliance. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on the review of personnel records, the facility failed to document that all personnel are trained to perform assigned task during emergencies in three out of four personnel records.
The findings include:
On June 5, 2012, four personnel records were reviewed for documentation of emergency training. The facility did not document that emergency training was provided so that all personnel on all shifts were trained to perform assigned tasks during emergencies. Three out of four records lacked documentation of emergency training, specifically, personnel records # 4, 5 and 6.
Personnel # 4 was hired on 11/21/11, but verification of this training was not documented until 5/23/12.
Personnel # 5 was hired on 4/11/12, but verification of this training was not documented until 5/9/12.
Personnel # 6 was hired on 4/28/12, but verification of this training was not documented until 5/9/12.
An interview with the facility director on June 5, 2012 confirmed the findings.
|
Plan of Correction
By August 1,2012 Director will ensure all staff attend an emergency procedure training upon hire. This training will ensure that all personnel on all shifts are trained to perform assigned task during emergencies. Director will monitor for on-going compliance. |
709.28(b) LICENSURE Confidentiality
709.28. Confidentiality.
(b) The project shall secure client records within locked storage containers.
|
Observations
Based on a physical plant inspection, the facility failed to secure all client records within locked storage containers.
The findings include:
An inspection of the facility ' s physical plant was conducted on June 5, 2012 between approximately 2:30 PM and 3:30 PM. Discharged client records were stored in plastic containers in a basement closet.
The basement closet was locked, but the closet was not being used exclusively for client record storage. At the time of inspection, the basement closet was being used as a multipurpose storage room. In addition to the discharged client records, the closet contained clothing, toys and various other items that were unrelated to client records or record storage.
An interview with project director confirmed the findings.
|
Plan of Correction
Effective September 1,2012 the Director will ensure that all client records are secured within a locked stoage container. Locked storage containers will be stored in a locked room for client records exclusively. Director will monitor for on-going compliance. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
|
Observations
Based on a review of client records, the facility failed to document treatment plans to include type and frequency of treatment and rehabilitation services in four out of four records reviewed.
The findings include:
On June 6, 2012, treatment plans in four client records were reviewed for documentation type and frequency of treatment and rehabilitation services, specifically records # 1, 2, 3 and 4. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 11/30/11. The treatment plan in client #1's record dated 12/20/11 did not include type and frequency of treatment and rehabilitation services.
Client # 2 was admitted on 1/6/12. The treatment plan in client #2's record dated 1/26/12 did not include type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on 4/20/12. The treatment plan in client #3's record dated 5/10/12 did not include type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on 5/7/12. The treatment plan in client # 4's record dated 5/26/12 did not include type and frequency of treatment and rehabilitation services.
An interview with the facility director on June 5, 2012 confirmed the findings.
|
Plan of Correction
Effective July 15,2012 Director will meet with staff for supervision to ensure that treatment plans include type and frequency of treatment and rehabilitation services. Director will monitor for on-going compliance. |