INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 2016 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Resources for Human Development Inc. Morris 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(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that all staff persons received at least 6 hours of HIV/AIDS and other health related topics within the regulatory timeframe in one of five personnel records reviewed.
Employee #5 was hired as a counselor on May 26, 2015 and was due to complete the HIV/AIDS training no later than May 26, 2016. The training was not documented at the time of inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with Employee #5 on 7/26/16 to review training requirements. The Employee has registered for 6 hours of HIV/AIDS Trainings using Department Approved Curriculum, to be completed by December 1st, 2016. The Director and Office Manager will conduct quarterly reviews of all employee training plans and training logs, to ensure that all staff are in compliance with regulatory timeframes. The Director will be responsible for ensuring that the corrective action is implemented. |
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 a review of the Clinical Team Calendar and the Recover Specialist Calendar, the facility failed to provide 24 hour coverage of CPR staff.
May 30, 2016 through July 1, 2016 work schedule was reviewed and the work schedule showed several days where staff worked and there was no CPR coverage. The facility is open 24 hours Sunday through Saturday.
The following dates and times reflect a lack of CPR coverage:
5-30-2016: 5 PM to 12 AM shift
5-31-2016: 5 PM to 12 AM shift
6-1-2016: 5 PM to 12 AM shift
6-4-2016: 5 PM to 12 AM shift
6-7-2016: 5PM to 12 AM shift
6-11-2016: 8 AM to 9 AM shift
6-11-2016: 5 PM to 9 PM shift
6-21-2016: 5 PM to 12 AM shift
6-22-2016: 5 PM to 12 AM shift
6-30-2016: 5 PM to 12 AM shift
7-1-2016: 5 PM to 12 AM shift
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CPR Requirements will be reviewed with all staff during an all-staff meeting on July 28, 2016, as well as with all new hires during their orientation session. The Director and Office Manager will institute procedures to ensure that all staff are re-certified before their CPR expires. The Director will meet with the Office Manager on 7/27/16 to review CPR Requirements and ensure that a CPR Staff is present on every shift on all future monthly schedules. The Director will ensure that the corrective action is implemented. |
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 fire drill record, the facility failed to document the number of persons in the facility at the time of the fire drill.
A review of the June 2015 through June 2016 fire drill record was reviewed during the annual licensing inspection. During the months of January 2016, February 2016 and June 2016, the facility failed to document the number of persons in the facility at the time of the fire drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will review the Fire Drill Record procedures and documentation at the 7/28/16 all staff meeting, as well as with new hires during their initial orientation, to ensure that all forms are completed fully and correctly, in compliance with the regulations. This will include the training of staff to document the number of persons in the building at the time of the fire drill. Forms will be checked monthly after completion of the drill by the Office Manager. The Director will be responsible for ensuring that the corrective action is implemented. |
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
The facility failed to obtain an informed and voluntary consent to release in nine of ten client records reviewed during the course of the annual licensing inspection on July 18, 2016.
Client #1 was admitted to treatment on March 8, 2016 and was still an active client at the time of inspection. Two consent forms dated March 8, 2016, the facility failed to document the name of the person, or organization to whom disclosure is being made, the specific information to be disclosed, and the purpose of disclosure.
Client #2 was admitted to treatment on May 13, 2016 and was still an active client at the time of inspection. A consent form dated May 13, 2016, the facility failed to document the name of the person, or organization to whom disclosure is being made, the specific information to be disclosed, and the purpose of disclosure. In addition, a consent form dated May 13, 2016, releasing to the clients family member, the facility failed to document the specific information to be disclosed, and the purpose of disclosure.
Client #3 was was admitted to treatment on March 15, 2016 and was still an active client at the time of inspection. Two consent forms dated March 15, 2016, the facility failed to document the name of the person, or organization to whom disclosure is being made, the specific information to be disclosed, and the purpose of disclosure.
Client #4 was was admitted to treatment on June 3, 2016 and was still an active client at the time of inspection. Two consent forms dated June 3, 2016, the facility failed to document the name of the person, or organization to whom disclosure is being made, the specific information to be disclosed, and the purpose of disclosure.
Client #5 was admitted to treatment on March 28, 2016 and discharged June 7, 2016. Two consent forms dated June 3, 2016, the facility failed to document the name of the person, or organization to whom disclosure is being made, the specific information to be disclosed, and the purpose of disclosure.
Client #7 was admitted to treatment on August 4, 2015 and discharged February 1, 2016. Two consent forms dated August 6, 2015, the facility failed to document the name of the person, or organization to whom disclosure is being made, the specific information to be disclosed, and the purpose of disclosure.
Client #8 was admitted to treatment on April 1, 2016 and discharged May 24, 2016. Two consent forms dated April 1, 2016, the facility failed to document the name of the person, or organization to whom disclosure is being made, the specific information to be disclosed, and the purpose of disclosure.
Client #9 was admitted to treatment on October 19, 2015 and discharged March 21, 2016. Two consent forms dated October 21, 2015, the facility failed to document the name of the person, or organization to whom disclosure is being made, the specific information to be disclosed, and the purpose of disclosure.
Client #10 was admitted to treatment on February 11, 2016 and discharged June 28, 2016. A consent form dated February 11, 2016, releasing to the clients family member, the facility failed to document the specific information to be disclosed, the purpose of disclosure, and a dated signature of the client. In addition, a consent form dated February 11, 2016, releasing to a Hospital, the facility failed to get a signature of a witness and a dated signature of the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will review regulations related to consents with the clinical team at their 7/27/2016 clinical team meetings, as well as with all staff at the 7/28/2016 staff meeting. During these meetings, the staff will be trained that all consents must document the name of the person, or organization to whom disclosure is being made, the specific information to be disclosed, and the purpose of disclosure, as well as all consents being properly dated and signed.
The Director will meet with client #1, #2, #3, and #4 by 8/1/16 to address the deficiencies in the consents noted in their charts. The director will revise the client intake packet by 8/15/16, to increase clarity about consents during the intake process. Additionally, effective 8/1/16, the director will conduct random monthly audits of 50% of active client files, to ensure that consents are in compliance with all regulations.
The Director will be responsible for ensuring these corrective actions are taken. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on a review of client records, the facility failed to document a physical examination in three of ten records reviewed.
Client # 2 was admitted to the facility on May 13, 2016, and was still an active client at the time of inspection. The facility failed to document that a physical examination was conducted on client #2 as of the date of the licensing inspection.
Client # 4 was admitted to the facility on June 3, 2016, and was still an active client at the time of inspection. The facility failed to document that a physical examination was conducted on client #4 as of the date of the licensing inspection.
Client #8 was admitted to the facility on April 1, 2016 and discharged on May 24, 2016. The facility failed to document that a physical examination was conducted on client #8 as of the date of the licensing inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The director will review the regulation pertaining to documentation of a physical exam for all clients during the 7/28/2016 all staff meeting. Additionally, the Director and Case Manager will implement new procedures for increasing access physical examinations for new clients by 9/1/2016. A completed physical form, signed by a medical provider for clients #2 and #4 will be obtained and placed in the charts by 9/1/16. The director will be responsible for ensuring that the corrective actions are completed. |