INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 15, 2021 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 the review of the Staffing Facility Requirements Summary Report and personnel records, the facility failed to ensure that all staff persons received the minimum of six hours of HIV/AIDS training and four hours of TB/STD training within the regulatory timeframe.
Employee #6, a Lead Recovery Specialist was hired on March 4, 2019 and was due to receive the minimum of six hours of HIV/AIDS training and four hours of TB/STD training no later than March 4, 2021; however, there was no documentation of the completion of HIV/AIDS or TB/STD trainings on file at the time of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Director will meet with Employee #6 by 9/1/2021 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 as soon as an available spot is located in an online traning. 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. |
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 an administrative review, the facility failed to ensure that a sufficient number of staff persons were certified in CPR and trained in first aid during the facility's hours of operation.
The facility's hours of operation are 24 hours a day, 7 days a week, 365 days a year. The facility provided documentation that only four employees had first aid certification. There was insufficient first aid coverage during the evening and overnight hours which are from 8pm to 8am for the period reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
CPR Requirements will be reviewed with all staff during an all-staff meeting during September 2021, as well as with all new hires during their orientation session. The Director and Office Manager will institute procedures to ensure that all staff are re-certified before their CPR expires. The Director will meet with the Office Manager by 9/1/2021to review CPR Requirements and ensure that a CPR Staff is present on every shift on all future monthly schedules. The Director will ensure that the corrective action is implemented. |
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors and facility directors during the training years reviewed.
Employee # 1 was hired as the Project Director on February 18, 2018. The personnel record documented 0 hours of annual training during the facility's July 1, 2019 through June 30, 2020 annual training year.
These findings were reviewed with facility staff as part of the inspection process.
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Plan of Correction
Program Director reviewed guidelines with the Assistant Regional Director on 8/10/2021. Regional Director will conduct a quarterly check of Project Director's training hours to ensure the Project Director has 12 clock hours of annual training. |
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 client records, the facility failed to obtain a written informed and voluntary consent from the client for the disclosure of information contained in the client record in one of seven client records reviewed.
Client # 2 was admitted on January 4, 2021 and was discharged on January 22, 2021. There was documentation of a disclosure to an emergency contact on January 22, 2021; however, there was no consent to release information form signed by the client documented in the record prior to the disclosure.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with the Morris Home clinical team on 8/12/2021 and reviewed expectations related to intake packets and consents, to ensure that there is a written informed and voluntary consent from the client for the disclosure of information contained in the client record. Documentation of this training was completed and placed in each staff member's personnel chart.
Director will follow up with Case Manager in individual supervision by 9/1/2021 and will document supervision in Case Manager's chart.
Director will ensure that training on consents is added onto on-boarding/training for all new hires.
The Director and Case Manager have adopted a new protocol where all intake packets will be completed by the Case Manager and given to the Director for signature and approval that all initial consents are completed correctly.
The Lead Therapist and Director will facilitate a quarterly audit, to ensure that all consents are completed correctly. If consents continue to contain errors, the Director will begin a corrective action plan with employees. The Director will be responsible for ensuring the Corrective Action Plan is implemented. |
709.28 (c) (1) 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 must be in writing and include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom a disclosure was to be made to on release of information forms in one of seven client records reviewed.
Client # 2 was admitted on January 4, 2021 and was discharged on January 22, 2021. A release of information form was signed and dated by the client on January 4, 2021; however, there was no documentation of the name of the person, agency, or organization to whom the disclosure was to be made to on the form.
This is a repeat citation from the November 18, 2020 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with the Morris Home clinical team on 8/12/2021 and reviewed expectations related to intake packets and consents, to ensure that all release forms document the name of the person, agency, organization to whom the disclosures will be made are properly documented. Documentation of this training was completed and placed in each staff member's personnel chart.
The Director and Case Manager have adopted a new protocol where all intake packets will be completed by the Case Manager and given to the Director for signature and approval that all initial consents are completed correctly.
The Lead Therapist and Director will facilitate a quarterly audit, to ensure that all consents are completed correctly. If consents continue to contain errors, the Director will begin a corrective action plan with employees. The Director will be responsible for ensuring the Corrective Action Plan is implemented. |
709.28 (c) (2) 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 must be in writing and include, but not be limited to:
(2) Specific information disclosed.
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Observations
Based on a review of client records, the facility failed to document the specific information to be released on consent forms in one of seven client records reviewed.
Client # 2 was admitted on January 4, 2021 and was discharged on January 22, 2021. A blank release of information form was signed and dated by the client on January 4, 2021; however, there was no documentation of the specific information to be disclosed on the form.
This is a repeat citation from the November 18, 2020 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with the Morris Home clinical team on 8/12/2021 and reviewed expectations related to intake packets and consents, to ensure that all release forms document the specific information to be disclosed. Documentation of this training was completed and placed in each staff member's personnel chart.
Director will follow up with Case Manager in individual supervision by 9/1/2021 and will document supervision in Case Manager's chart.
Director will ensure that training on consents is added onto on-boarding/training for all new hires.
The Director and Case Manager have adopted a new protocol where all intake packets will be completed by the Case Manager and given to the Director for signature and approval that all initial consents are completed correctly.
The Lead Therapist and Director will facilitate a quarterly audit, to ensure that all consents are completed correctly. If consents continue to contain errors, the Director will begin a corrective action plan with employees. The Director will be responsible for ensuring the Corrective Action Plan is implemented. |
709.28 (c) (3) 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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to document the purpose of disclosure on consent forms in one of seven client records reviewed.
Client # 2 was admitted on January 4, 2021 and was discharged on January 22, 2021. A blank release of information form was signed and dated by the client on January 4, 2021; however, there was no documentation of the purpose of the disclosure on the form.
This is a repeat citation from the November 18, 2020 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Director met with the Morris Home clinical team on 8/12/2021 and reviewed expectations related to intake packets and consents, to ensure that all release forms document the the purpose of disclosure. Documentation of this training was completed and placed in each staff member's personnel chart.
The Director and Case Manager have adopted a new protocol where all intake packets will be completed by the Case Manager and given to the Director for signature and approval that all initial consents are completed correctly.
The Lead Therapist and Director will facilitate a quarterly audit, to ensure that all consents are completed correctly. If consents continue to contain errors, the Director will begin a corrective action plan with employees. The Director will be responsible for ensuring the Corrective Action Plan is implemented. |