INITIAL COMMENTS
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This report is a result of an on-site licensing inspection conducted on April 12, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site licensing inspection, Resource 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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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on the review of fire drill documentation, the facility failed to conduct unannounced fire drills at least monthly.
The findings include:
A review of fire drill documentation revealed that the facility failed to conduct fire drills during the months of February 2011, December 2012, and January 212.
The Facility Director confirmed this finding.
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Plan of Correction
In response to citation 705.28, a plan has been put in place to guarantee completion of monthly fire drills. The DUI Supervisor has been assigned responsibility to conduct monthly fire drills and complete required documentation in the Fire Drill log book. This staff will be supervised in this capacity by the program Director. Fire Drills have been conducted in consecutive months since March 2012. |
709.91(b)(3)(i) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a completed medical history in one of five client charts reviewed.
The findings include:
Five client records were reviewed on April 12, 2012. One of five client records failed to include a medical history in the client record.
Client # 3 was admitted on 01-19-2012; the project failed to include a medical history in the client record.
A conversation with the Facility Director on April 12, 2012 confirmed this finding.
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Plan of Correction
In reference to citation for lack of medical history (709.91), the chart for client #3 has been corrected and the required documentation completed on 4/25 by Therapist #1. These changes were confirmed by Assistant Director. Therapist #1 received a verbal reprimand for documentation error. Verbal instruction and training materials outlining needed chart documentation were provided to all staff. Additionally, a lead therapist was identified to conduct all initial intake appointments for consistent evaluations and will be supervised by the Director of the program. This change was made as of 4/25/12 and is currently taking place. |
709.91(b)(3)(ii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to include a drug and alcohol history in one of four client records.
The findings include;
A review of client records on April 12, 2012 revealed the facility failed to include the drug and alcohol history in record # 3.
Client #3 was admitted on 01-19-201;.the project failed to complete the drug and alcohol history in the client record.
The Facility Director confirmed this finding on April 12, 2012.
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Plan of Correction
In reference to citation for lack of a drug and alcohol history (709.91), the chart for client #3 has been corrected and the required documentation completed on 4/25 by Therapist #1. These changes were confirmed by Assistant Director. Therapist #1 received a verbal reprimand for documentation error. Verbal instruction and training materials outlining needed chart documentation were provided to all staff. Additionally, a lead therapist was identified to conduct all initial intake appointments for consistent evaluations and will be supervised by the Director of the program. This change was made as of 4/25/12 and is currently taking place. |
709.91(b)(3)(iii) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Following a review of client records, the facility failed to include documentation of a personal history in one of five client records.
The findings include:
A review of five client records on April 12, 2012, revealed the facility failed to include a personal history in client record # 3 who was admitted January 19, 2012.
The Facility Director confirmed this finding on April 12, 2012.
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Plan of Correction
In reference to citation for lack of a personal history (709.91), the chart for client #3 has been corrected and the required documentation completed on 4/25 by Therapist #1. These changes were confirmed by Assistant Director. Therapist #1 received a verbal reprimand for documentation error. Verbal instruction and training materials outlining needed chart documentation were provided to all staff. Additionally, a lead therapist was identified to conduct all initial intake appointments for consistent evaluations and will be supervised by the Director of the program. This change was made as of 4/25/12 and is currently taking place. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of five client records, the facility failed to include a psychosocial evaluation in one of five client records.
The findings include;
Five client records were reviewed on April 12, 2012. Client record # 3 did not include a psychosocial evaluation.
The Facility Director confirmed this finding.
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Plan of Correction
In reference to citation for lack of a psychosocial evaluation (709.91), the chart for client #3 has been corrected and the required documentation completed on 4/25 by Therapist #1. These changes were confirmed by Assistant Director. Therapist #1 received a verbal reprimand for documentation error. Verbal instruction and training materials outlining needed chart documentation were provided to all staff. Additionally, a lead therapist was identified to conduct all initial intake appointments for consistent evaluations and will be supervised by the Director of the program. This change was made as of 4/25/12 and is currently taking place. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. 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:
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Observations
Based on a review of the project's policies and procedures manual and client records, the facility failed to complete individualized treatment and rehabilitation plans per the project's policy.
The findings include:
Five client records were reviewed on April 12, 2012. The facility failed to provide documentation of an individual treatment and rehabilitation plan in client record #3.
The finding was confirmed by the Facility Director.
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Plan of Correction
In reference to citation for lack of a treatment plan in client #3's chart (709.92), further review of this citation led to a finding that the required treatment plan had been completed but had been removed from the chart to be signed by the program Medical Director. Staff has been trained on parameters of treatment planning and provided with written training documentation as of 4/25/12. Assistant Director will monitor charts and conduct weekly audits to ensure compliance. |