INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 18, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, RHD - Family House, was found to be not in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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705.2 (1) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(1) Maintain all structures, fences and playground equipment, when applicable, on the grounds of the facility so as to be free from any danger to health and safety.
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Observations
The facility failed to ensure that the bottom of the fence in the children's play area was adequately maintained and free from safety concerns as that portion of the fencing was broken. Additionally, the trash dumpster, located behind the facility, did not have the lids closed.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Any staff member at Family house will inform the Program Manager and/or the Program Director when there is building issue such as a broken fence so that it can be repaired immediately. The fence that was broken has been repaired by our facility maintenance company.
Staff will ensure that lids on the dumpsters are closed at all times. Checking the dumpster lids will be added to the ADL rounds sheet to ensure the lids are closed at all times. Staff have also informed the program participant when taking out the trash to ensure the lids on dumpster are closed. |
709.28 (c) 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.
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Observations
The facility failed to document a valid witness signature/date, as well as the expiration date for a consent to release information form in one of seven client records reviewed.
Client # 4 was admitted on March 1, 2017 and was discharged on August 1, 2017. A release of information form to a pharmacy was signed and dated by the client on March 1, 2017.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Program Director will have a training with all clinical and ADL staff to ensure the correct completion of the consent form. The training will consist of making sure that each consent will have a expiration date and a valid witness signature on all consent along with what is to be released and the completion of the form as a whole. The training will be completed for the day staff on August 10th and for the evening staff on Aug 13th. |