INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 24, 2023 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 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
Based on a review of personnel files and the Staffing Requirement Facility Summary Report, the facility failed to ensure all staff persons completed at least 4 hours of tuberculosis, sexually transmitted diseases, and other health related topics training within the regulatory time frame in one of six personnel records reviewed
Employee #6 was hired as a life skills specialist on July 1, 2021. The TB/STD training was due to be completed no later than July 1, 2023; however, there was no documentation that the training was completed as of the date of the inspection.
This is a repeat citation from the July 15, 2021 and July 8, 2022 annual licensing renewal inspections.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
During the onboarding process, all newly hired employees will be registered for all DDAP required trainings by the program Office Manager as a part of the onboarding process. The Program Director will review employee charts quarterly as a quality review to ensure all staff attended the trainings as assigned.
Employee #6 has been registered for and will complete TB/STD on 9/19/2023. |
705.6 (4) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(4) Provide privacy in toilets by doors, and in showers and bathtubs by partitions, doors or curtains. There shall be slip-resistant surfaces in all bathtubs and showers.
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Observations
Based on a physical plant inspection, conducted on July 24, 2023 between 10:15 AM and 10:30 AM, the facility failed to provide slip-resistant surfaces in all bathtubs and showers as a communal bathroom shower on the second floor and a communal bathroom shower on the third floor did not have a slip-resistant surfaces.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The slip resistant mats have been placed in the bathrooms. The Office Manager will quality check mats every 30 days as part of the completion of a monthly property checklist. The Regional Director will conduct a facility walkthrough and checklist quarterly to ensure mats are present and in good condition. |
709.23 LICENSURE Project Director
§ 709.23. Project director.
Project directors shall prepare, annually update and sign a written manual delineating project policies and procedures.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to document that the project director had prepared, annually updated, and signed the facility's written manual, which delineates the project policies and procedures.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project Director reviewed the Policy and Procedure Manual following the inspection and signed off on the form that has been placed in the binder. The Regional Director created a yearly review sign off sheet for the policy and procedures. The Regional Director will ensure the Project Director will review and sign annually. |
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 ensure that treatment plans were reviewed and updated at least every 30 days in three of seven client records reviewed.
Client #4 was admitted September 1, 2022 and was discharged November 7, 2022. A treatment plan update was completed on September 27, 2022 and the next update was due no later than October 27, 2022; however, the update was not completed at the time of the inspection.
Client #6 was admitted January 18, 2023 and was discharged May 11, 2023. The individual treatment plan was completed on January 27, 2023 and the first update was due no later than February 27, 2023; however, the update was not completed at the time of the inspection.
Client# 7 was admitted February 28, 2023 and was discharged June 16, 2023. A treatment plan update was completed on April 21, 2023 and the next update was due no later than May 31, 2023; however, the update was not completed at the time of the inspection.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Clinical Manager will track treatment plan due dates from admission for each client. The Clinical Manager will conduct monthly chart audits to ensure treatment plans are completed timely. The Program Director will conduct chart audits quarterly to ensure all documentation has been completed as scheduled.
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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 administrative documents, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for failing to ensure all staff persons received the HIV/AIDS training and the TB/STD training within the regulatory timeframe were submitted and approved by the department for the July 15, 2021 and July 8, 2022 annual licensing inspections. Failing to ensure that all staff were trained for the HIV/AIDS training and the TB/STD training was again found to be a deficiency in the July 24, 2023 licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the onboarding process, all newly hired employees will be registered for all DDAP required trainings by the program Office Manager as a part of the onboarding process. The Program Director will review employee charts quarterly as a quality review to ensure all staff attended the trainings as assigned. |