INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 22, 2021 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 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)(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 the review of the staff schedule, the facility failed to provide enough staff persons so that at least one person trained in these skills was onsite during the project's hours of operation.
There was no staff certified in CPR on the 11 PM to 7 AM shift on July 5, 2021.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
- RHD CORE will hold quarterly CPR trainings to be sure those who are close to expiration can complete prior to expiration.
- Fiscal Administrator will keep a running log on a spread sheet displaying what trainings are due for each staff.
- Unit Director will review the training log monthly, and assign CPR training to any staff that are within 3 months of expiration.
- Staff person that was not trained during shift noted in citation was trained on 7/23/21. |
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 the review of personnel records, the facility failed to ensure that counselors received at least 25 clock hours of annual training in one of one personnel record.
Employee # 2 was hired as a counselor on July 16, 2018. There were only 3 hours of training documented for the July 1, 2020 to June 30, 2021 training year.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
- All staff will maintain a personal training log that Clinical Supervisor will monitor in monthly supervisions.
- Clinical supervisor will assist with linking staff with continuing education resources, to ensure staff are able to both fulfill the 25 hour requirement, and provide them with trainings of their interest.
- Unit Director will also assign trainings that were established in annual training plan.
- For this citation: staff have been instructed that all of their last f/y trainings must be completed by 8/20/21. |
705.6 (5) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(5) Ventilate toilet and wash rooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the bathrooms were ventilated by an exhaust fan or window.
The staff bathroom and two client rooms did not have an operable fan or window.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Work order was submitted to building owner on 8/5/21.
- Building owner inspected the system and reported it to be functioning.
- Unit Director met with maintenance on 8/23/21 where it was demonstrated that all ventilation systems were in tact and functioning.
- Unit Director will check system on a quarterly basis and report any malfunction to maintenance. |