INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 21- 22, 2007 by staff from the Division of Drug and Alcohol Program Licensure. 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 and a plan of correction is due on September 21, 2007.
|
Plan of Correction
|
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.
|
Observations
Based on a review of three personnel records and a staff interview it was determined that the facility failed to ensure that employee #3 received the minimum of 6 hours of HIV/AIDS training within the first year of employment.
The findings were:
The Personnel record review for employee #3 was conducted on August 22, 2007. No documentation was found regarding the employees attendance for a minimum of 6 hours HIV/AIDS training. Based on the facility director's documentation on the Staffing Requirements Facility Summary Report and an interview with the facility director on August 22, 2007, it was confirmed that employee #3 did not receive the required training.
|
Plan of Correction
Director will ensure that staff member are compliant with training as required by the state. In addition, Director has obtained state cirriculum to hold training locally and therefore give more opportunity for trainings to occur. Director will meet with Unit Assistant monthly to review training.
Staff member will attend HIV/AIDS training on October 10, 2007. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
|
Observations
Based on a review of the fire drill log documentation and a staff interview it was determined that the facility failed to conduct a fire drill during sleeping hours within the past six months.
The findings were:
A review of the fire drill log was conducted on August 22, 2007. The last documented fire drill during sleeping hours occurred in November 2006 at 3:15 AM. A conversation with the facility director on August 22, 2007 confirmed that no fire drill was conducted during sleeping hours within the last six months.
|
Plan of Correction
Director will continue to monitor the compliance of the fire drill schedule. In addition, monthly the fire drill log will be reviewed by the Director and/or ADL coordinator to ensure compliance. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
|
Observations
Based on a review of administrative documentation it was determined that the project failed to make the annual report available to the public within the time period stated in the project's policy manual.
The findings were:
During the review of the project's policy manual an advertisement receipt from ACME Newspaper, Inc. indicated that RHD- Family House's July 1, 2005 - June 30, 2006 annual report would be available for public review on June 21, 2007. The project's policy stated that the annual report would be made available to the public no later than six months from the end of the project's fiscal year
|
Plan of Correction
The Annual Report for Family House Norristown was completed within the expected timeframe of state regulations but was ommitted from the documents given to the inspector. In the future the Program Director will ensure that the annual report will be submitted along with other required documents so deficiency will not recur. |
709.26(f)(2) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(2) Tasks and responsibilities of the job.
|
Observations
Based on a review of the job description specifications for Activities of Daily Living Counselor (ADL Counselor), which is a non-clinical position, and an interview with the facility director it was determined that the facility failed to ensure that the tasks and responsibilities assigned to this position were non-clinical.
The findings were:
A review of the job description for ADL Counselors on August 22, 2007 indicated that there were some responsibilities for clinical activities which included, but were not limited to providing conflict resolution, attending and/or facilitating specialty groups as assigned by the project director, conducting individual sessions and completing progress notes. An interview with the facility director on August 22, 2007 confirmed that the job description was the most current job description for the ADL Counselors.
|
Plan of Correction
A revised job description for the ADL counselor position will be utilized removing clinical tasks from this job description. |
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. The consent shall be in writing and include, but not be limited to:
|
Observations
Based on a review of three client records it was determined that the facility failed to release confidential client record information according to the facility's policy and failed to comply with 4 Pa. Code Subsection 255.5(b).
The findings were:
Client record #1: The Pennsylvania Client Placement Criteria (PCPC) form contained documentation in Dimension #1 that referred to specific drugs that the client used. Dimension #3 listed the specific medications and the dosage used by the client. The back of the form contained documentation related to the client's treatment plan goals.
Client record #1: A copy of a letter written by the client's counselor and sent to the Women, Infant and Child (WIC) program was found in the client's record without a signed consent to release information form for the WIC program.
Client record #2: The PCPC form contained documentation in Dimension #3 that listed the specific medications and the dosage used by the client.
Client record #2: A signed consent to release information form between Community Behavioral Health (CBH) managed care and Family House/Womanspace contained the release of the client's psychological history and drug and alcohol history. It was determined that the release of information form for CBH managed care exceeded the limitations imposed at 4 PA. Code, subsection 255.5(b).
Client record #3: The PCPC form contained documentation in Dimension #3 that listed the specific medications and dosage used by the client.
|
Plan of Correction
Confidentiality procedures will be reviewed by Director with staff members during staff meeting.
In addition, clinical chart audit will be conducted monthly to ensure compliance with confidentiality laws.
Confidentiality policy was performed on September 29, 2007 during a staff meeting to ensure that compliance is maintained. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
|
Observations
Based on a review of three client records and discussion with the facility director it was determined that the facility failed to ensure that the physician properly and timely documented client physical examinations.
The findings were:
The physical examination form failed to include the client's pulse rate and temperature in one of three client records reviewed, specifically client record #3.
The physical examination form reviewed in client record #2 was dated March 22, 2006, but the physician's signature on the form was dated March 27, 2007. According to documentation reviewed in the client record and the active client list presented by the facility director the client was admitted to treatment on March 14, 2007. The facility's policy stated that the physical examination will be completed within seven days of the client's admission.
|
Plan of Correction
Director will ensure that physicals occur in a timely manner in accordance to our policy. In addition, forms will be reviewed upon completion by the doctor so that any typographical error can be corrected immediately.
Once a client is accepted into the program Director or designee will ensure that appointment for physical is made. After the physical is complete, Director or designee will review and initial the report for compliance. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records and discussion with the facility director it was determined that the facility failed to complete a psychosocial evaluation in one of three client records reviewed, specifically client record #3.
The findings were:
The psychosocial was never completed for client record #3. A review of the client record and discussion with the facility director confirmed that the client was admitted to treatment on May 29, 2007. A dated staff signature of June 8, 2007 was documented on the psychosocial evaluation form with no further information. The client record and client discharge summary list presented by the facility director indicated that the client was discharged from the facility on July 15, 2007.
|
Plan of Correction
Director will review complete chart audits on a monthly basis. In addition, all clinical documentation is submitted to Director for review on a weekly basis. |
709.53(a)(10) LICENSURE Discharge Summary
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:
(10) Discharge summary.
|
Observations
Based on a review of three client records and discussion with the facility director it was determined that the facility failed to complete a discharge summary for client record #3.
The findings were:
A review of client record #3 and discussion with the facility director confirmed that the discharge summary was missing. A review of the facility's policy stated that the discharge summary is to be completed within seven days of the client's discharge.
|
Plan of Correction
Prior to a client's departur the clinical chart to be submitted for a final audit by Director. In addition, all clinical documentation must be submitted to Director on a weekly basis for review. This is to ensure compliance with documentation timelines. |
709.53(a)(11) LICENSURE Follow-up information
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:
(11) Follow-up information.
|
Observations
Based on a review of two client records and discussion with the facility director it was determined that the facility failed to document follow-up on discharged clients based on the facility's own policy.
The findings were:
In one of two client records reviewed, specifically client record #3, the follow-up documentation was missing. The facility's policy regarding follow-up for unsuccessfully discharged clients is 30 after discharge. According to information reviewed in client record #3, the client was discharged in July 15, 2007. A discussion with the facility director on August 22, 2007 confirmed that no follow-up was conducted for client record #3.
|
Plan of Correction
Prior to a client's departure the clinical chart to be submitted for a final audit by Director. In addition, all clinical documentation must be submitted to Director on a weekly basis for review. Follow up documentation must be submitted as required. This is to ensure compliance with documentation timelines.
The clinical team, under the leadership of the Director will hold a follow-up reveiw of the clients 2 weeks after discharge to ensure the follow-up documentation has been completed. |