INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 23, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Resources 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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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
The facility failed to ensure that employee #3, a counselor hired on January 15, 2017, received both of the required communicable disease trainings within the regulatory timeframe, based on a review of the facility's Staffing Requirement Facility Report and the employee's personnel file.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #3 is registered to attend the required trainings on the following dates:
Basic HIV training offered through DDAP September 19, 2018
TB/STD/Hepatitis C training offered through DDAP on September 25, 2018
Unit Director will ensure these trainings are attended and that completion certificates are obtained and filed in the employee's personnel chart.
Unit Director will ensure that all future employees hired will attend necessary trainings within the 1st year of hire by including on the training plan for new employees.
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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
The facility failed to document the number of people in the facility at the time of the drill on all of their fire drill logs. This was discovered based on the review of the October 2017 through June 2018 logs.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Unit Director reviewed current form for logging fire drills on 07/23/18 and made necessary corrections to include the number of participants in fire drills. New form is being utilized immediately. Previous form listed names of attendees; revised form has a place to fill in the number of attendees to alleviate any discrepancies. |
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 information form prior to the disclosure of information in 2 of 14 client records reviewed. Additionally, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on a consent form in 1 of 14 client records reviewed
Client #3 was assessed in the intake, evaluation, and referral level of care on March 2, 2018 and was completed on March 14, 2018. There was documentation that contact was made to another treatment provider on March 9 and March 11, 2018; however, there was no consent to release information documented in the record prior to the disclosures.
Client #7 was assessed in the intake, evaluation, and referral level of care on March 29, 2018. A consent to release information form was signed/dated on March 29, 2018; however, the form failed to include the name of the person, agency, or organization to whom the disclosure was to be made to.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Unit Director reviewed these findings directly with individuals who did not obtain proper consent from clients on 07/23/18. This information is reviewed during training when an employee is hired. Unit Director reiterated guidelines for disclosure of information and obtaining consent to release information via email to team on 07/23/18. In addition, Unit Director will review these guidelines during the next group supervision for clinicians on 08/24/18. This information will be reviewed again at the next all-staff meeting on 09/14/18. Ongoing training will occur by: continuing to incorporate this material into new-hire training, reviewing periodically in individual and group supervisions, reviewing in all-staff meetings. |