INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 26, 2017 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 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 records, the facility's Staffing Requirement Facility Summary Report (SRFSR) form and verification from the facility director, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in 2 of 6 personnel records reviewed.
Employee #5 was hired as an Activity Daily Living staff member on 3/10/08. Employee #5 was due to complete the required HIV/AIDS and TB/STD trainings no later than 3/10/10. There was no documentation in the employee file indicating that the employee received the HIV/AIDS or TB/STD trainings as of the date of the inspection.
Employee #6 was hired as an Activity Daily Living staff member on 5/10/15. Employee #6 was due to complete the required HIV/AIDS and TB/STD trainings no later than 5/10/17. There was no documentation in the employee file indicating that the employee received the HIV/AIDS or TB/STD trainings as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Office Manger will schedule all newly hired employees for their mandated training especially HIV/AIDS and TB/STD in the allotted time frame. Employee # 5 and employee #6 will be scheduled to attend the required training's as soon as the training's become available.Director will work with the office manager to ensure the employees are scheduled in a timely manner. |
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 a review of personnel records and the facility's staff employment calendar for the month of June 2017, the facility failed to demonstrate sufficient coverage of staff certified in CPR and/or First Aid during the project's hours of operation during the shifts listed below.
June 3, 2017 12:00 A.M.-12:00 P.M. - No CPR coverage
June 11, 2017 04:00 P.M.-12:00 P.M. - No First Aid coverage
June 17, 2017 04:00 P.M.-12:00 P.M. - No First Aid coverage
June 24, 2017 04:00 P.M.-12:00 P.M. - No First Aid coverage
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The office manager will schedule employees for CPR/First Aid prior to the expiration date. Employee who worked the shift June 3 has not been scheduled for any shifts and will not be able to work until she has completed CPR and First Aid which is currently scheduled for September 8, 2017. The employee would did not have First aid will not work a shift alone until she has taken first aid training. Director will ensure the training are scheduled in a timely manner. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, it was observed that the facility failed to ensure that all bathrooms were operating in a functional and safe manner. The sink in the second floor bathroom was not securely affixed to the wall and was able to easily be pulled away from the wall.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The sink in the second floor bathroom has been secured to the wall. Day ADL staff will be assigned to make sure that all repairs to the physical plant are reported to our maintenance company, Director and then repaired in a timely fashion. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on a physical plant inspection on July 26, 2017 at approximately 01:45 P.M., the temperature of the facility's freezer, located in the kitchen, was measured at 22 degrees.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The freezer temperature was not at 0F due to the stripping on the freezer being slit. The stripping on the freezer was replaced and the temperature as been at 0F.
The ADL staff will let the Director and the day ADL know when the temperature of the freezer is above 0F so that that the maintenance company can come and make the necessary repairs.
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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based a review of fire drill records for July 2016 through June 2017, the facility failed to document that a fire drill was conducted during sleeping hours at least every 6 months. The facility conducted a fire drill at 12:10 A.M. in November 2016 but did not conduct another fire drill during sleeping hours until June 2017. Additionally, the log for the fire drill conducted in March 2017 did not indicate whether the fire alarm or smoke detector was operative.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
The program Director will completed a schedule of fire drills which will consist of dates and times and shifts that fire drills will be conducted ensuring that a fire drill will be conducted at least every 6 months during sleeping. The Director will check and make sure they fire drill during sleeping hours was completed in a timely fashion. |
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
Based on a review of seven client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in five records. Additionally, there were consent to release information forms missing required information in three records.
Client #1 was admitted on 9/1/16 and discharged on 4/17/17. The record contained a letter that was sent to a government agency on 9/7/16, which identified the client's presence in treatment and the nature of the project. However, the consent to release information form, signed on 9/1/16, did not authorize the facility to release the nature of the project to the recipient. Additionally, the record contained documentation of faxes to a pharmacy on 2/11/17 and 11/4/16, which identified the client's presence in treatment, for whom there was no signed consent to release information form in the client record prior to the disclosure.
Client #3 was admitted on 4/24/17 and discharged on 7/18/17. The record contained a letter that was sent to a government agency on 5/8/17, which identified the client's presence in treatment and the nature of the project. However, the consent to release information form, signed on 4/25/17, did not specifically authorize the facility to release that information.
Client #4 was admitted on 4/27/17 and discharged on 7/7/17. The record contained a letter sent to a court on 6/13/17, which disclosed the client's presence in treatment, urinalysis results, and progress in treatment, for which there was no signed consent to release information form prior to the disclosure. Additionally, the record contained two consent to release information forms signed on 6/6/17 to outside agencies, and one form indicated that "other information" was to be released but did not specify details, and the other form indicated other reasons for the purpose of disclosure, but did not specify details.
Client #6 was admitted on 3/29/17 and was an active client at the time of inspection. The record contained a letter that was sent to a court on 5/8/17, which identified the client's presence in treatment and the nature of the project. However, there was no signed consent to release information form to the recipient in the record prior to disclosure. Additionally, the record contained documentation of a fax to a pharmacy on 4/5/17, which identified the client's presence in treatment and medications, for whom there was no signed consent to release information form in the client record prior to the disclosure.
Client #7 was admitted on 5/9/17 and was an active client at the time of inspection. The record contained a letter that was sent to a probation officer on 5/11/17, which identified the nature of the project. However, the consent to release information form, signed on 5/10/17, did not authorize the facility to release the nature of the project to the recipient. Additionally, a letter was sent to the probation officer on 5/5/17, which was 5 days prior to the client signing a consent to release information form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff that are responsible to complete consents and consent to release forms will be trained on how to appropriately complete the forms. Training will be done by the Director and training will include:completing the consent prior to discourse of information, completing all information on the consent to release form, not sending any letters, faxes without the proper release from the member, to only release the specific information that the member authorizes Family House to release,
member #1 #2 #3 #4 #5 have been discharged so no corrections can be made to consents.
# 6 will Lead Therapist will updated the release for court and the drug store will be completed correctly. #7 an updated consent for the PO will be corrected for future information needing to be released. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of seven client records, five client records contained consent to release information forms which did not indicate that the clients had been offered copies.
Client #1 was admitted on 9/1/16 and discharged on 4/17/17. The record contained consent to release information forms, signed on 9/1/16, to a government agency and another treatment provider, which did not indicate that the client was offered a copy of the form.
Client #2 was admitted on 9/14/16 and discharged on 1/16/17. The record contained a consent to release information form, signed on 9/29/16, to a family member, which did not indicate that the client was offered a copy of the form.
Client #3 was admitted on 4/24/17 and discharged on 7/18/17. The record contained three separate consent to release information forms, signed on 4/26/17, which did not indicate that the client was offered a copy of the forms.
Client #4 was admitted on 4/27/17 and discharged on 7/7/17. The record contained a consent to release information form, signed on 5/4/17, which did not indicate that the client was offered a copy of the form.
Client #5 was admitted on 5/25/17 and was an active client at the time of inspection. The record contained a consent to release information form, signed on 7/14/17, to another treatment provider, which did not indicate that the client was offered a copy of the form.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The staff member that completes the consent forms will ensure that the member initials the box that states that they have been offered a copy of the form by initialing yes they were offered a copy of the form. Lead Therapist will check charts during a chart audit to ensure that the members are being offered a copy of the form and are initialing the correct box.
Member #5 who was active at the time of the inspection was left treatment on 8/2/2017 so the consent can not be corrected. |
709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on a review of seven client records, the facility failed to provide a complete client record in three client records.
Client #2 was admitted on 9/14/16 and was discharged on 1/16/17. The client record did not contain documentation of follow-up information or a discharge summary as of the date of the inspection.
Client #3 was admitted on 4/27/17 and was discharged on 7/18/17. The client record did not contain documentation of follow-up information as of the date of the inspection.
Client #4 was admitted on 4/27/17 and was discharged on 7/7/17. The client record did not contain documentation of follow-up information as of the date of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each Therapist discharging a member from treatment will contact the discharged member and or the program the member was referred to by phone and or email at 7 days after discharge and then at 30 days after discharge to obtain the follow up information. The lead Therapist will review the chart for completion of the follow up 7 days after discharge and 30 days after discharge from treatment to ensure that the appropriate follow forms were completed within the allotted time frames.
Therapist will set reminders on their calendar to complete the follow up information at 7 days from a member being discharged and then at 30 days from discharge and the form completed on
time.
Discharge summary for # 2 will be completed 8/30/2017 by Director therapist at that time is no longer her. Director was present at time of discharge.
Follow up on #2 #3 #4 will be completed by the Director by 8/30/2017.
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