INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 6, 2022 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of personnel records, the facility failed to ensure that the facility director met the appropriate experiential qualifications for the position in one of one applicable personnel record reviewed.
Employee #2 was hired as the facility director on October 1, 2021. The personnel record documented that the facility director had a master ' s degree; however, the employee did not have any documented experience in program planning prior to being hired.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The resume for Employee #2 has been updated to reflect program planning experience.
Moving forward, the Regional Director will ensure that any candidates for the Facility Director role have met and documented the appropriate qualifications for the position. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. There were three fire extinguishers within the facility that were last inspected in October 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
RHD notified management for the
property, who arranged for inspection of
the fire extinguishers on July 12, 2022.
All of the fire extinguishers within the
facility were inspected at that time. A
request will be made to property
management for annual inspections, with
the next inspection occurring prior to
July 2023. |
709.28 (c) (4) 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:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of a client on informed and voluntary consent to release information forms in two of fourteen client records reviewed.
Client #4 was admitted on August 26, 2021 and was discharged on November 16, 2021. There were release information forms to an emergency contact, a funding source, a primary care physician, another treatment facility, and a government agency signed by the witness on August 26, 2021; however, the dated signature of the client was not documented on any of the forms.
Client #9 was admitted on September 9, 2021 and was discharged on October 1, 2021. There was a release information form to a government agency signed by the witness on September 9, 2021; however, the dated signature of the client was not documented on the form.
This is a repeat citation from the July 27, 2021 and March 11, 2021 annual licensing renewal inspections.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
A procedure was put into place following
the previous inspection, but not until
after these releases were completed for
Client #4, that physical signatures must
be obtained and verbal consent is not
sufficient for releases of information.
Currently, physical signatures are
obtained from every client for each
release of information. All RHD staff are
aware that verbal consent is not
sufficient and all new staff will be
trained in this manner, as well.
Client #9 was evaluated while
incarcerated at Montgomery County
Correctional Facility and a staff member
at the correction facility obtained the
client's signature on the form, but not a
date. Moving forward, RHD staff will
ensure that all client signatures are
accompanied by the date of the
signature. If they receive signed forms
that do not include a signature date, they
will request that the correctional facility
obtain the signature date from the client
and send the document again.
Compliance with these procedures will
be monitored through supervision and
monthly chart audits.
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709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to accurately document the dated signature of a witness on informed and voluntary consent to release information forms in one of fourteen client records reviewed.
Client #1 was admitted on May 18, 2022 and was active at the time of inspection. There were release of information forms to an emergency contact and another treatment facility signed and dated by the client on May 31, 2022; however, the signature of the witness was dated June 1, 2022.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
With the delivery of treatment services
via telehealth, releases of information
are being sent to clients electronically
for signatures. In this instance, the
clinician did not receive the signed
document back from the client in time to
sign as a witness on the same day. To address this issue, new releases were completed and signed by both the client and the witness on August 3, 2022.
Moving forward, RHD staff will
coordinate with clients in order to ensure
that the client and witness signatures
occur on the same day.
Compliance with this procedure will be
monitored through supervision and
monthly chart audits. |
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 must be in writing and include, but not be limited to:
(6) Date, event or condition upon which the consent will expire.
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Observations
Based on a review of client records, the facility failed to document the date, event or condition upon which a consent to release information form will expire in one of fourteen client records reviewed.
Client #7 was admitted on April 14, 2022 and was discharged on June 1, 2022. There was a release of information form to another treatment facility signed by the client on April 14, 2022; however, there was no documented date, event, or condition for when the consent would expire on the form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
When obtaining signatures from
clients electronically, a formula is
utilized to calculate the
appropriate expiration date. In
this instance, an error occurred
with the formula and the expiration date was replaced with a "0."
Moving forward, when RHD staff
receive a signed electronic document,
they will review the document
thoroughly for completeness and
accuracy. If any errors are found they
will make corrections and have the
client sign again, if appropriate.
Compliance with this procedure will be
monitored through supervision and
monthly chart audits. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every 60 days in two of four applicable client records reviewed.
Client #3 was admitted on February 8, 2022 and was active at the time of inspection. The comprehensive treatment plan was completed on April 28, 2022 and an update was due no later than June 28, 2022; however, there was no update documented as of the date of the inspection.
Client #4 was admitted on August 26, 2021 and was discharged on November 16, 2021. The comprehensive treatment plan was completed on September 13, 2021 and an update was due no later than November 13, 2021; however, there was no update documented prior to discharge.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
For Client #3, the clinician had not
updated the treatment plan within the
required time frame due to client
absences and not having an opportunity
to meet with the client to review
progress. A treatment plan update was completed on July 1, 2022 and the next update will be completed prior to August 30, 2022.
In regards to Client #4, the clinician did
not complete the required treatment plan update due to a planned discharge for
three days later.
Moving forward, RHD staff will
complete all treatment plan updates
within the required time frame. Since the
client's signature is not required for
treatment plan updates, client absences
will not interfere with the completion of
updates.
In addition, treatment plan updates will
be completed within the required time
frame regardless of any discharge plans.
This will be monitored through ongoing
clinical and administrative supervision
and monthly chart audits. |
709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for obtaining the dated signature of the client on consent forms were submitted and approved by the Department for the July 27, 2021 and March 11, 2021 annual licensing inspections. Not obtaining the dated signature of the client on consent forms was again found to be a deficiency in the July 6, 2022 licensing inspection.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The identified deficiency has been
reviewed thoroughly and with all
program staff. Procedures have been
changed to eliminate the possibility of a
recurrence of this deficiency. |