INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, 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 January 20, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. 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 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(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on the review of personnel records, the facility failed to document an annual written individual staff performance evaluation on one of two personnel records.
Employee record # 1 did not document a 2019 annual written performance evaluation.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It is the responsibility of the Unit Director to ensure that the Annual Training Plan is completed for all staff. This Performance Evaluation is based on the employees' hire/anniversary date.
It is the responsibility of the Fiscal Administrator to notify staff and their supervisor when an Annual Performance Evaluation is due and the responsibility of the Unit Director to ensure they are completed and available in the employee chart for review. |
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 document an annual written individual staff performance evaluation in one of two personnel records.
Employee record # 1 did not document a 2019 or 2020 annual written performance evaluation.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
It is the responsibility of the Unit Director to ensure that the Annual Performance Evaluation is completed for all staff. This Annual Performance Evaluation on all employees that is based on the employees hire/anniversary date.
It is the responsibility of the Fiscal Administrator to notify staff and their supervisor when an Annual Performance Evaluation is due and the responsibility of the Unit Director to ensure they are completed. |
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
Based on the review of client records, the facility failed to obtain an informed and voluntary consent in one of seven client records.
Client record # 5 documented a letter sent to a pharmacy on May 8, 2020. There was no documentation of a release.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the annual licensure inspection conducted on September 16 - 17, 2019.
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Plan of Correction
It is part of our intake process to get consent to release information to our pharmacy, and it is unclear why there was no documentation that this release existed.
Our correction plan is that we will have a checklist that will document all consents that were signed by the client. The consents will then be scanned into our EHR, where we will use the checklist to then verify that all were added successfully. The paper copies will be retained as backup.
Any consent not completed will be rectified, or documented as "Client Declined to Sign."
Unit Director will have bottom line responsibility for ensuring that this plan is followed.
The Resource Coordinator is responsible for getting consents filled out and signed by each client upon admission. These are then reviewed by the Unit Director before they are scanned into the electronic health record. Any additional consents signed by a client during their stay at the program will be approved by the Unit Director, documented on the consent checklist by the Resource Coordinator, before being scanned into the Electronic Health Record. |
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
Based on the review of client records, the facility failed to obtain an informed and voluntary consent from the client in seven of seven client records.
In client records # 1, 2, 3, 4, 5, 6 and 7, releases for the urinalysis testing laboratory were documented. The information to be released did not include that the patient's urine sample could be sent.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
At our exit interview, our reviewer directed us to the consent form that our Beaver County facility is using, and that the other facility's form met the criteria for compliance with this issue. We have since begun using that consent at CORE Allegheny County program.
This consent has been corrected by the Unit Director and Resource Coordinator since the last licensing review. As it is electronically generated, the old version has been deleted.
This consent will be filled out by the client during admission, and will be facilitated by the program's Resource Coordinator. When complete, this consent (along with all other consents) will be reviewed by the Unit Director before they are scanned into the electronic health record.
This consent has been corrected by the Resource Coordinator for all of the clients in the program.
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709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the unusual incident reports, the facility failed to file a written unusual incident report with the Department within 3 business days following an unusual incident involving an event at the facility requiring the presence of police, fire or ambulance personnel.
An ambulance was present at the facility on October 7, June 26, and March 14, 2020. Ambulance and police were present at the facility on January 5, 2021. There was no documentation that the incidents had been reported to the Department.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the annual licensure inspection conducted on September 16 - 17, 2019.
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Plan of Correction
Effective immediately, staff have been directed that all incident reports will be routed through the Unit Director, who will ensure that responses to incidents are being reported accurately, clearly, and to the correct authority, and with the appropriate forms, and with confirmation forms that the information was correctly submitted to DDAP.
Incident reports will be filed in the Unit Director's office and reviewed monthly.
At our exit interview, we were provided with the most current information and criteria for reporting incidents to DDAP. |