INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11-12, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Morris Home was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a review of the "Staffing Requirements Facility Summary Reports" (SRFSR) for all of the facilities in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
The SRFSRs for the eleven facilities that make up the project list a total 21.75 FTE counselor positions within the project. This includes clinical supervisors carrying a caseload greater than that permissible.
A full-time equivalency of 21.75 counselors would require a minimum of 2 full-time clinical supervisors and one part-time clinical supervisor within the project.
This finding was confirmed with the project director during the administrative review.
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Plan of Correction
Morris Home met the requirement for the Clinical Supervisor; she currently holds a Master's Degree with over three years of Drug ans Alcohol experience. The Clinical Supervisor, works 35 hours a week administrative and 5 hours a week clinical. Caseload shall not exceed 2 individuals. Morris Home will collaborate with the other facilities within the project quarterly to ensure there are continuosly two full-time clinical supervisors. |
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 personnel records and CPR/First Aid certification cards, the facility failed to ensure that a sufficient number of staff persons were trained in CPR and First Aid.
The findings include:
All employee CPR/First Aid certification cards were reviewed on July 11, 2013. There was several staff that didn't have training for CPR and First Aid who worked on various shifts. The facility is open 24 hours Sunday through Saturday. A two month work schedule was reviewed and showed several days where staff worked and there was no CPR or First Aid coverage.
Did not have sufficient coverage on the following days and time:
4pm to 12 am
June 16, 18, 19, 25 and 26
July 2, 3, 4, 9 and 10
12 am to 8 am
June 29
July 6 and 13
8am to 4pm
June 29
An interview with the facility director on July 12, 2013, confirmed the findings.
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Plan of Correction
Effective on July 12, 2013, The director and office manager revised the staff pattern to ensure there is at least one staff per shift who is CPR/First Aide certified. An additional 10 staff were trained in CPR and First Aide on Tuesday, July16, 2013. When completing the weeking staffing schedule, the office manager will make sure at least one staff is certified. The Director will review staff certification quarterly. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of the fire drill record, the facility failed to prepare alternate exit routes to be used during fire drills.
The findings include:
Fire drill record was reviewed on July 11, 2013. The fire drills conducted from July 2012 - July 2013 were reviewed. Per regulation, the residential facility shall prepare alternate exit routes to be used during fire drills. The facility only documented the front door as the exit used during fire drills for the following months: July 2012, August 2012, October 2012, November 2012, January 2013, March 2013, April 2013, May 2013, June 2013 and July 2013.
An interview with the facility director on July 12, 2013 confirmed the findings.
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Plan of Correction
Effective August 2013, Morris Home will alternate between the back door and front door when conducting monthly fire drills to ensure compliance. Staff will continue to document exit routes on a monthly basis. The director will meet with the recovery specialist, who are responsible for completing monthly fire drills, on a quaretly basis to ensure this is taking place. |
709.53(a)(10) LICENSURE Discharge Summary
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(10) Discharge summary.
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Observations
Based on a review of client records, the facility failed to include components in the discharge summary.
The findings include:
Eight client records were reviewed on July 12, 2013. Four of the eight were discharge clients, #5, 6, 7 and 8. The following components are required to be documented on the discharge summary; reason for treatment, services offered, respond to treatment and client status. The facility failed to include reason for treatment, on the discharge summary for client's #5, 6 and 8.
Also, discharge summaries are to be completed with 7 days of the client's discharge date. Client #7 was admitted on May 3, 2012 and discharged on January 24, 2013. The discharge summary was to be completed by January 31, 2013. At the time of the inspection there was no discharge summary documented in client #7's record.
An interview with facility staff on July 12, 2013, confirmed the findings.
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Plan of Correction
The Clinical Manager will review all discharged files within six days of discharge to ensure summaries are completed and include the followinf information:
- Reason for treatment,
- Services offered,
- Response to treatment
- Client status.
The director will complete quarterly chart audits to ensure this is taking place, and will then meet with Clinical program manager to discuss finsings. |