INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 9, 2008 through June 10, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD Family 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 and a plan of correction is due on July 11, 2008.
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Plan of Correction
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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 the personnel and training records and the staffing schedules, the facility failed to provide a sufficient number of staff persons on each shift who were First Aid trained. There was no First Aid trained staff person working from 4:00 PM to 12:00 AM on 5/26/08, 5/27/08, 5/28/08 and 6/7/08.
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Plan of Correction
1. Program Director will revised ADL schedule to ensure that all shifts are covered by staff members with appropriate CPR & First Aid training.
2. Staff member without First Aid training will be trained in the next available training session.
3. Program Director along with Office Mananger will review all incoming new hire documentation to ensure that staff members have necessary documentation prior to working.
This corrective action plan will go into effect as of 6/25/08. |
705.2 (3) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(3) Keep exterior exits, stairs and walkways lighted at night.
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Observations
Based on the physical plant inspection conducted on June 9, 2008, the facility failed to ensure proper lighting for the external fire escape on the second floor of the facility. The light for the second floor fire escape was broken, both the bulb and the surrounding glass casing were shattered.
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Plan of Correction
1. During the inspection, this deficency was corrected.
2. Program Director will perform that monthly property inspections are conducted to ensure proper lighting for the external fire escapes throughout the facility.
Corrective Action Plan effective 6/25/08. |
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
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Observations
Based on the physical plant inspection conducted on June 9, 2008 the facility failed to ensure that the emergency exit routes were unobstructed. The door to the tertiary means of egress from the second floor, located near the internal staircase, was stuck and had to be forced open by the licensing specialist in order to gain egress to the outside.
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Plan of Correction
1. This deficeny was corrected during the inspection.
2. Program Director will perform monthly property inpsections to ensure that there are no obstructions in all exit routes.
Corrective Action plan will be effective 06/25/08 |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of the administrative documentation and the annual report for the July 2006 to June 2007 fiscal year, the facility failed to document the notification of the annual report to the public.
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Plan of Correction
1. Program Director along with Office Manager will contact local newspaper will change current notification process.
2. Notification will occur during the first three months of the new fiscal year to ensure compliance.
Corrective Action Plan will be effective 6/25/08. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of facility policy and procedure and personnel records, the facility failed to document work performance evaluations within the facility's identified time frame in two of three records reviewed, #3 and 4. The policy stated that new employees would receive their first performance evaluation within two weeks after the completion of the probationary period and all other employees would have a performance evaluation completed no later than July 30 of every year. The performance evaluation for employee #3 was due 7/30/07, but was not completed until 8/16/07. The performance evaluation for employee #4 was due 11/15/2007, but was not completed until 2/04/2008.
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Plan of Correction
1. Program Director and Office Manager will ensure that all peformance evaluations are conducted in compliance to program policies and procedures.
2. A montly audit of personel files will be conducted by Program Director to ensure compliance.
Corrective Action Plan will be effective 6/25/08. |
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 shall be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent including the specific information to be disclosed in two of four records reviewed, #3 and 4. The specific information to be disclosed was not documented on seven of 13 consent forms in one record, #3. The specific information to be disclosed was not documented on five of nine consent forms in one record, #4.
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Plan of Correction
1. The program consent form has been revised to meet disclosure requirements.
2. Program Director will conduct monthly audits of client charts to ensure continued compliance with respect to disclosure information.
Corrective Action Plan effective 06/25/08. |
709.28(c)(6) 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 shall be in writing and include, but not be limited to:
(6) Expiration date of the consent.
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Observations
Based on a review of client records, the facility failed to document the expiration date of the consents to release information in two of four records reviewed, #2 and 4. The expiration date was missing on seven of 11 consents to release information in record #2. The expiration date was missing on six of nine consents to release information in record #4.
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Plan of Correction
1. Consent form has been changed to include expiration date.
2. Program Director will conduct monthly client chart audits to ensure continued compliance with standard.
Corrective Action Plan effective 06/25/08. |
709.32(c)(2) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(2) Drug storage areas.
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Observations
Based on an inspection of the medication area, the facility failed to keep food items separate from medications in the medication designated refrigerator.
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Plan of Correction
1. All food items have been removed from the medication designated refrigerator.
2. A new sign will be placed on the refrigerator marked "Medication Only."
3. Program Director along with ADL Cooridinator will conduct monthly property inspections to ensure continued compliance.
Corrective Action Plan effective 06/25/2008.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of the client records, the facility failed to document complete psychosocial evaluations in three of three client records reviewed, #2, 3 and 4. Psychosocial evaluations did not include an assessment of the client's assets/strengths, support systems, and negative factors that may inhibit treatment.
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Plan of Correction
1. Program Director will conduct an in-service training with all clinical staff to include an assessment of the client's assets/strengths, support systems, and negative factors that may inhibit treatment.
2. Program Director will conduct monthly client chart audits to ensure compliance.
Corrective Action Plan will be effective 06/25/08. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document complete treatment plan updates in four of four records reviewed, #1, 2, 3 and 4. The treatment plan updates did not include an assessment of the client's progress in relationship to the stated goals of the prior treatment plans.
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Plan of Correction
1. Program Director will conduct an in-service training to include assessment of the client's progress in relationship to the stated goals of the prior treatment plans.
2. Program Director will conduct monthly client chart audits to ensure compliance.
Corrective Action Plan will be effective 06/25/08. |
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
Based on a review of client records, the facility failed to document that counseling services were provided as indicated on individual treatment and rehabilitation plans in four of four records reviewed, #1, 2, 3 and 4.
Client #1 was to attend individual treatment sessions once a week, as per the treatment plan, but the client record did not document any individual treatment sessions from 3/4/08 to 4/2/08.
Client #2 was to attend individual treatment sessions once a week, as per their treatment plan, but the client record did not document any individual treatment sessions from 1/5/08 to 2/1/08; 2/3/08 to 2/6/08 and 4/12/08 to 5/20/08.
Client #3 was to attend individual treatment sessions once a week, as per their treatment plan, but the client record did not document any individual treatment sessions from 4/28/08 to 5/21/08.
Client #4 was to attend individual treatment sessions once a week, as per their treatment plan, but the client record did not document any individual treatment sessions from 4/7/08 to 4/22/08.
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Plan of Correction
1. All clinical documentation will be submitted to Program Director on a weekly basis to ensure compliance.
2. Program Director will conduct monthly client chart audits to ensure compliance.
Corrective Action Plan will be effective as of 06/25/08. |
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 document complete case consultations every 90 days, as per project policies, in three of three records reviewed, #1, 2 and 3. Case consultations did not include the disposition of the cases reviewed in three records, #1, 2 and 3. Client record #1 was missing one of two case consultations. Client record #2 should have had a case consultation completed in February 2008, but it was not completed until 4/15/08. Client record #3 should have had a case consultation completed at the end of March 2008, but it was not completed until 4/15/08.
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Plan of Correction
1. Program Director and Office Manager will establish a case consultation schedule to ensure that case consultations occur in accordance with program policy and procedure.
2. Program Director will conduct monthly client chart audits to ensure compliance.
Corrective Action Plan will be effective 06/25/08. |