INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 26, 2025 by staff from the Department of Drug and Alcohol Programs, Bureau of 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(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to ensure a written individual training plan, for each employee, was developed annually and with input from both the employee and the supervisor in two of five applicable personnel records reviewed.
Employee # 4 was hired as a counselor on December 11, 2024. There was no documentation indicating the individual training plan for the current 2024-2025 training year was completed at the time of the inspection.
Employee # 5 was hired as a counselor on April 29, 2020 and was no longer employed as of May 2025. There was no documentation indicating the individual training plan for the current 2024-2025 training year was completed at the time of the inspection.
This is a repeat citation from the May 6, 2024 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director, Office Manager and Clinical Manager will ensure all employees have a written individual training plan with input from both supervisor and employee. These will continue to be monitored by ongoing supervisions, staff meetings, and employee chart reviews. Individual training plans will be completed by July 31, 2025 for the training year of 2025-2026.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to ensure each counselor completed at least 25 clock hours of annual training, during the July 1, 2023 through June 30, 2024 training year, in two of two applicable personnel records reviewed.
Employee # 3 was hired as a counselor on May 31, 2021. The personnel record documented seven hours of training received during the training year reviewed.
Employee # 5 was hired as a counselor on April 29, 2020 and was no longer employed as of May 2025. The personnel record documented zero hours of training received during the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Program Director, Office Manager and Clinical Manager will ensure all employees completed at least 25 clock hours of annual training during the 2025-2026 training year. These will continue to be monitored by monthly supervisions that will review training hours-to-date to ensure progress is tracked throughout the year, monthly staff meetings to explain the expectations of all staff in regards to training, and employee chart reviews to ensure training is correctly filed. By August 1st Program Director, Office Manager and Clinical Manager will begin to track the completion of training hours. |
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
Based on a physical plant inspection, the facility failed to ensure cold food was kept at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
At the time of the inspection, conducted at approximately 1:00 pm, the refrigerator, located in the kitchen, registered a temperature of 52 degrees Fahrenheit and the freezer, also located in the kitchen, registered a temperature of 10 degrees Fahrenheit.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By July 21, 2025, the refrigerator and freezer had been fixed. Program Director, Office Manager and Property Manager will monitor for on-going compliance. |
709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on the review of personnel records, the facility failed to ensure the completion of annual written individual staff performance evaluations, which shall be reviewed and signed by the employee, in one of two applicable personnel records reviewed.
Employee # 5 was hired as a counselor on April 29, 2020 and was no longer employed as of May 2025. There was no individual performance evaluation, for the previous year, documented in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The Program Director and Clinical Manager will ensure that all employees have a completed, written individual annual evaluation, signed by both the supervisor and the employee. These evaluations will be continuously monitored through employee chart reviews. All individual staff evaluations will be completed by July 31, 2025.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on an administrative review, the facility failed to maintain a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relation to its stated goals and objectives.
The facility had a hybrid system of electronic (EMR) and paper client records. During the course of the on-site inspection, facility staff was unable to retrieve the complete paper records for all requested clients in a timely manner.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will utilize our Electronic Health Record to ensure timely and organized data entry, secure storage, and efficient retrieval by August 15,2025.The management of this system will continuously be monitored by the Program Director, Office Manager, and Clinical Manager. A standardized template stating what is required for client chart data and a data dictionary will be developed to ensure uniformity and compliance and provided to staff responsible for data entry. Staff responsible for data entry will be trained on the new system and protocols by Clinical Manager and Program Director. Internal audits of the data collection system will be conducted by the Clinical Manager for the next 12 months to ensure completeness, accuracy, and accessibility of data.
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709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of the facility's decision to involuntarily terminate the client's treatment at the project in one of one applicable client records reviewed.
Client # 7 was admitted on June 25, 2024 and was involuntarily terminated on August 2, 2024. There was no documentation, in the record, indicating the client received written notice of the involuntary termination from the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By August 29,2025 the Program Director and Clinical Manager will train all staff on how to notify clients in writing of the program's decision to involuntarily terminate the client's treatment. Director and Clinical manager will monitor through staff supervisions, chart audits, and staff meetings for on-going compliance. |
709.33 (b) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on a review of client records, the facility failed to provide the client an opportunity to request reconsideration of a decision terminating treatment in one of one applicable client record reviewed.
Client # 7 was admitted on June 25, 2024 and was involuntarily terminated on August 2, 2024. There was no documentation, in the record, indicating the client was given an opportunity to request reconsideration of the involuntary termination from the project.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will provide an administrative discharge document that will include steps for a client to appeal and an opportunity to request reconsiderations of the decision to terminate treatment from the facility. Clients will be made aware of the appeal process directly when informed of the intent to discharge and allow the client to appeal the decision. This will be placed in the client record. The Program Director and Clinical Manager will train all staff in the administrative discharge process by August 29, 2025. The Program Director and Clinical manager will monitor through chart audits, staff meetings, and supervision for on-going compliance. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to a maintain a complete client record on an individual, which is to include the documentation of case consultation notes, in one of one applicable client record reviewed.
Client #2 was admitted on March 11, 2025 and was active at the time of inspection. There was no documentation of case consultation notes in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Clinical Manager and Program Director will ensure case consultation documentation notes for clients who have been in treatment for 90-days as required. Clinical Manager will create a tracker document to monitor due date of upcoming case consultations for active client load and communicating them to therapists weekly. Program Director and Clinical Manager will collaborate with the clinical team in scheduling case consultations and completing documentation within 24 hours of case consultation meeting. This will be implemented by 8/1/2025.
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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 a maintain a complete client record on an individual, which is to documentation of discharge summaries, in three of four applicable client records reviewed.
Client #4 was admitted on October 30, 2024 and was discharged on January 14, 2025. There was no discharge summary documented in the record as of the date of the inspection.
Client #5 was admitted on July 23, 2024 and was discharged on September 20, 2024. There was no discharge summary documented in the record as of the date of the inspection.
Client #6 was admitted on November 5, 2024 and was discharged on December 27. 2024. There was no discharge summary documented in the record as of the date of the inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By July 25, 2025, the facility will maintain a complete client record which will include documentation of discharge summaries. The Clinical Manager will supervise the clinicians to ensure completion of discharge summaries within 24-hours of discharge. Clinical Manager will discuss progress of discharge summary documentation in supervision with clinicians. The Program Director will monitor charts for on-going compliance.
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709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document a complete client record, which is to include documentation of follow-up information, in four of four applicable records reviewed.
Client #4 was admitted on October 30, 2024 and was discharged on January 14, 2025. There was no follow-up information documented in the record as of the date of the inspection.
Client #5 was admitted on July 23, 2024 and was discharged on September 20, 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client #6 was admitted on November 5, 2024 and was discharged on December 27. 2024. There was no follow-up information documented in the record as of the date of the inspection.
Client #7 was admitted on June 25, 2024 and was discharged on August 2, 2024. There was no follow-up information documented in the record as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Manager, Life Skills Specialist, Program Director or Therapist will complete documentation follow-up. The Program Director and Case Manager will monitor the completion of follow-up documentation through chart audits, staff meetings and/or supervisions. This will be implemented by July 25, 2025. |