INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the June 15-16, 2009 licensure renewal inspection. The follow-up inspection was conducted on December 31, 2009 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up 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 January 30, 2010.
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Plan of Correction
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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 CPR certification records and a review of the staff schedule, the facility failed to document CPR training for a sufficient number of staff persons.
The findings include:
CPR certification records and the staff schedule were reviewed on December 31, 2009. The facility was required to document CPR certification to a sufficient number of staff persons. The facility did not have at least one staff member with CPR certification on each shift. The CPR certification for personnel #1 expired on December 1, 2009.
The facility did not have CPR coverage on the 12:00 AM to 8:00 AM shift on December 5, 25 and 26, 2009.
The facility did not have CPR coverage on the 4:00 PM to 12:00 PM shift on December, 4, 2009.
The facility did not have CPR coverage between the hours of 10:00 PM to 12:00 AM on December, 12, 2009
An interview with the facility director was conducted on December 31, 2009. The facility director confirmed that they did not have at least one staff member with CPR certification on each shift.
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Plan of Correction
Program Director along with Office Manager will continue to schedule all CPR trainings for staff members that are due.
Program Director along with Office Manager will monitor monthly the staff members that CPR certification are due.
Prior to staff members being scheduled, Office Manager will approve staff members to work only if CPR certification is current. |
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 the review of client records, the facility failed to document a treatment plan update in one of two client records.
The findings include:
Seven client records were reviewed on December 31, 2009. Two of the seven records required documentation of treatment plan updates. The facility did not document a treatment plan update at least every thirty days in client record # 6.
Client # 6 was admitted to the program on 8/12/09. The treatment plan, in client record # 6, was dated 9/1/09, but the treatment plan updates were dated 10/29/09, and 12/8/09.
An interview with the facility director was conducted on December 31, 2009. The facility director confirmed that their policy is to document a treatment plan update at least every 30 days.
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Plan of Correction
Program Director will review staff submission of Treatment Plans during weekly case consultation session to ensure compliance.
Program Director will review client charts on a monthly basis to ensure compliance with treatment plan due dates.
This plan will be implemented immediately. |