INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on November 18, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
The facility failed to ensure that all frozen food was at or below 0 fahrenheit. Based on a physical plant inspection, three freezers, all located in the kitchen, had temperatures that were measured above 0 findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will consult with the Office Manager and Property Manager about repairs to the freezer, including arranging for the coils to be cleaned. If the current freezers are unable to maintain a temperature at or below 0 Farenheit, new freezers will be ordered by 12/15/2020.
Recovery Specialist Staff will complete the daily temperature checks to ensure that the temperature remains at an appropriate temperature.
The Office Manager will conduct Monthly Reviews of the temperature logs to check that the machines are working efficiently and correctly. |
709.28 (c) (1) 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. The consent must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
The facility failed to ensure that all release of information forms documented the name of the person, agency, or organization to whom the disclosure would be made to in two of seven client records reviewed.
Client # 6 was admitted on September 9, 2019 and was discharged on October 27.2019. A release of information form, in the record, was signed and dated by the client on September 9, 2019.
Client # 7 was admitted on January 21, 2020 and discharged on March 13, 2020. A release of information form, in the record, was signed and dated by the client on January 21, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will meet with the Morris Home clinical team and review expectations related to intake packets and consents, to ensure that all release forms document the name of the person, agency, organization to whom the disclosures will be made are properly documented.
The Director and Case Manager have adopted a new protocol where all intake packets will be completed by the Case Manager and given to the Director for her signature and approval that all initial consents are completed correctly.
The Lead Therapist and Director will facilitate a quarterly audit, to ensure that all consents are completed correctly. |
709.28 (c) (2) 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. The consent must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
The facility failed to keep disclosures of client identifying information within the limits established by 4 Pa. Code 255.5 (b) for releases of information in seven of seven client records reviewed. Additionally, the facility failed to identify specific information to be disclosed in three of seven client records.
Client # 1 was admitted on December 16, 2019 and was active at time of inspection. A release of information form to a government agency was signed and dated by the client on December 16, 2019 that allowed for the release of monthly expenses and financial obligations, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client # 2 was admitted on March 19, 2020 and was active at time of inspection. A release of information form to a government agency was signed and dated by the client on March 19, 2020 that allowed for the release of monthly expenses and financial obligations, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, a release of information to a outside individual was signed and dated by the client on March 19, 2020 and did not include the specific information to be disclosed.
Client # 3 was admitted on June 17, 2020 and was active at time of inspection. A release of information form to a government agency was signed and dated by the client on June 17, 2020 that allowed for the release of monthly expenses and financial obligations, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client # 4 was admitted on September 12, 2019 and was discharged on March 2, 2020. A release of information form to a government agency was signed and dated by the client on September 12, 2019 that allowed for the release of monthly expenses and financial obligations, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client # 5 was admitted on October 3, 2019 and discharged on December 3, 2019. A release of information form to a government agency was signed and dated by the client on October 3, 2019 that allowed for the release of monthly expenses and financial obligations, all of which exceeds the limits established by 4 Pa. Code 255.5.
Client # 6 was admitted on September 9, 2019 and discharged on October 27, 2019. A release of information form to a government agency was signed and dated by the client on September 9, 2019 that allowed for the release of monthly expenses and financial obligations, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, there was a release of information form signed and dated by the client on September 9, 2019 that did not indicate the specific information to be disclosed.
Client # 7 was admitted on January 21, 2020 and discharged on March 13, 2020. A release of information form to a government agency was signed and dated by the client on January 21, 2020 that allowed for the release of monthly expenses and financial obligations, all of which exceeds the limits established by 4 Pa. Code 255.5. Additionally, there was a release of information form signed and dated by the client on January 21, 2020 that did not indicate the specific information to be disclosed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director amended the consent forms in our intake packet as they relate to DHS, so that they will no longer indicate a release for monthly expenses and financial obligations. Director will review the limits of 4Pa. Code 255.5 with the Case Manager by 12/4/2020.
The Director and Case Manager have adopted a new protocol where all intake packets will be completed by the Case Manager and given to the Director for her signature and approval that all initial consents are completed correctly.
The Lead Therapist and Director will facilitate a quarterly audit, to ensure that all consents are completed correctly. |
709.28 (c) (3) 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. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The facility failed to ensure that all release of information forms documented the purpose of disclosure in three of seven client records reviewed.
Client # 2 was admitted on March 19, 2020 and was active at time of inspection. A release of information form to an outside individual was signed and dated by the client on March 19, 2020 and did not indicate the purpose of disclosure.
Client # 6 was admitted on September 9, 2019 and discharged on October 27, 2019. A release of information form was signed and dated by the client on September 9, 2019 and did not indicate the purpose of disclosure.
Client # 7 was admitted on January 21, 2020 and discharged on March 13, 2020. A release of information form was signed and dated by the client on January 21, 2020 and did not indicate the purpose of disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with the Clinical Team on 12/9/2020 to review expectations related to intake packets and consents, to ensure that all release forms indicate the purpose of disclosure.
For active clients, new consents indicating the purpose of disclosure will be completed by 12/15/2020
The Lead Therapist and Director will facilitate a quarterly audit, to ensure that all consents are completed correctly. |
709.52(c) LICENSURE Provision of Counseling Services
709.52. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
The facility failed to assure that counseling services were being provided according to the individual treatment and rehabilitation plan in three of seven client records reviewed.
Client # 1 was admitted on December 16, 2019 and was active at time of inspection. The comprehensive treatment plan indicated that the client was to recieve individual counseling sessions during treatment. However, there was no documentation in the record of individual counseling sessions occurring during the weeks of March 8, 2020 through April 18, 2020.
Client # 2 was admitted on March 19, 2020 and was active at time of inspection. The comprehensive treatment plan indicated that the client was to recieve individual counseling sessions during treatment. However, there was no documentation in the record of individual counseling sessions occurring during the weeks of May 3, 2020 through July 11, 2020.
Client # 4 was admitted on September 12, 2019 and was discharged on March 2, 2020. The comprehensive treatment plan indicated that the client was to recieve individual counseling sessions during treatment. However, there was no documentation in the record of individual counseling sessions occurring during the weeks of November 11, 2019 through January 11, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director will meet with the Clinical team on 12/9 and will review expectations related to scheduling of individual therapy sessions in accordance with individual's treatment plan. Additionally, Morris Home staff will develop a policy for documenting client individual session refusal. Director will also review expectations for timely submission of notes.
The Lead Therapist will conduct a weekly audit of note submissions to ensure that a note has been submitted for each individual treatment session.
The Lead Therapist and Director will facilitate a quarterly audit, to ensure consistency with note submission. |