INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 15, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Resources for Human Development Inc. Morris 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:
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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 #4, a counselor hired on May 27, 2018, 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
Director will meet with Employee #4 by 9/1/2019 to review training requirements. Director will ensure that the employee is registered for 6 hours of HIV/AIDS Trainings using Department Approved Curriculum, to be completed on 12/1/2019. The Director and Office Manager will conduct quarterly reviews of all employee training plans and training logs, to ensure that all staff are in compliance with regulatory timeframes. The Director will be responsible for ensuring that the corrective action is implemented. |
705.9 (1) LICENSURE General safety and emergency procedures.
705.9. General safety and emergency procedures.
The residential facility shall:
(1) Be free of rodent and insect infestation.
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Observations
The facility failed to ensure that the facility was free of rodent infestation. Based on a physical plant inspection conducted at approximately 9:30am, it was observed that the kitchen had mouse droppings in both of the upper and lower kitchen cupboards.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
Director will work with Property Manager and Building Maintenance to ensure that any repairs necessary to prevent mice from entering the physical plant are completed, as well as scheduling a meeting with our Pest Control vendor to review our monthly treatment plan and best practices. Director and Property Manager will complete a walk-through inspection of the property by 9/15/2019 to ensure that the facility is free of rodent infestation. Finally, the Director will review best practices with staff during an all-staff meetings, so that staff may assist members with proper cleaning and food storage techniques, also to be completed by 9/15/19. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
The facility failed to document a physical examination for four of seven client records reviewed .
Client #2 was admitted on January 1, 2019 and was still active at the time of the inspection.
Client #5 was admitted on December 11, 2018 and was discharged on April 1, 2019.
Client #6 was admitted on January 5, 2019 and was discharged on March 12, 2019.
Client #7 was admitted on June 4, 2018 and was discharged on October 17, 2018.
These finding were reviewed with facility staff during the licensing process.
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Plan of Correction
The Director and Clinical team will work with RHD Divisional Leadership to locate healthcare providers who are able to provide transgender competent health care, without a significant wait time for a initial physical. The Director will review the procedure for collecting the physical form and ensuring it is in the chart with the Clinical Team and Direct Service Staff during an all staff meeting. Director will ensure these protocols are in place by 10/1/2019. |