INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 30, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD New Start II 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 October 16, 2007.
|
Plan of Correction
|
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of four personnel records and discussion with the facility director it was determined that the facility failed to ensure that staff members completed a feedback form on all training attended. A review of two of four personnel records, specifically records #2 and 4, on August 29, 2007 indicated that feedback forms were not completed for all training attended.
|
Plan of Correction
The facility did not consistently collect the data for training from all staff due to many trainings being held off-site. Therefore, the Administrative Manager and Clinical Supervisor,will ensure that the feedback forms are collected. The Admi. Manager will distribute and collect the forms at the time certificate is returned to her. She has begun the process and the expected date of total compliance is 10/26/2007. On-goining complience will be monitored by Cl. Supervisor who will perform a monthly check during Quality Assurance meetings. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
|
Observations
Based on a review of the physical plant conducted on August 30, 2007 it was determined that the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit. A review of the physical plant conducted on August 30, 2007 at 10:30 AM revealed that the hot water temperature in the bathroom on the third floor was 128 degrees Fahrenheit.
|
Plan of Correction
The facility did not have the water to the proper temperature at time of the visit. During the visit the water temperature was adjusted. In order to ensure compliance the Residential team leader will take the water temperature weekly and record it on the weekly log. The log will be reviewed by the Residential Supervisor, C. Rutherford who will adjust the temperature as needed and record any adjustments on the log. This will be in compilance by 10/1/07 |
705.10 (b) (2) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(2) On floors with resident bedrooms, maintain a smoke detector which shall be located within 15 feet of each bedroom door. On floors with no resident bedrooms, the smoke detection device shall be located in a common area or hallway. All detection devices shall be interconnected.
|
Observations
Based on a physical plant review conducted on August 30, 2007 and a discussion with the facility director it was determined that the facility failed to ensure that a smoke detector device was located in a common area. A review of the physical plant conducted on August 30, 2007 at 10:30 AM revealed that a smoke detector was missing in the group room in the garage area.
|
Plan of Correction
During the site visit on 9/30/2007 the smoke detector had fallen off of the wall and could not be located, so the Residential supervisor purchased a detector and had it installed before the end of the site visit. It was inspected by the facility director, C. Thomas. In order to ensure on-going compliance with this regulation the Fire Captain will inspect the group area during the monthoy drill and note that it is still present and operational. The Res. Supervisor will sign off on the drill log. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
|
Observations
Based on a review of the fire drill log and discussion with the facility director it was determined that the facility failed to set off the fire alarm or smoke detector during each fire drill. A review of the fire drill log on August 30, 2007 indicated that no fire alarm or smoke detector was set off during each fire drill.
|
Plan of Correction
Although the facility does utilize the fire alarm test button or a somke detector to conduct drills we have failed to log it, therefore the fire drill form has been revised (as of 9/10/07). The designated fire captain conducting the drill will fill out the log to indicate what device was used. The residential supervisor will conduct a training for all staff on comprehensive fire safety, extinquisher training and how to complete the log properly. |
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, the facility failed to make the annual report available to the public within the time period stated in the project's policy manual. During a review of the project's policy manual, an advertisement receipt from ACME Newspaper, Inc. indicated that RHD- New Start II'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 was completed and available however the facility director failed to obtain the newspaper ad due to wanting to create a more formalized report. The Facility Director will obtain the ad by 10/31/07 and ensure that future ads are placed by the designated date. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
|
Observations
Based on a review of the project's policy manual and two client records, the facility failed to inform the client of the client's right to verbally revoke a consent to release information. A review of the project's policy manual on August 28, 2007 indicated that the facility failed to develop confidentiality procedures informing the client of the client's right to verbally revoke a consent to release information. The facility failed to document that client's were informed of their rights to verbally revoke a consent to release information in two of two records reviewed, #1 and 2.
|
Plan of Correction
Our current release of information is worded that the consent can be revoked in writing, although we inform the client that verbbal revocation is permissible. The facility director has added a line to the client right sheet that states the client has the right to revoke a consent at anytime and revocation can be verbal or in writing. In addition, the consent of information itself will be changed to state revocation can be verbal or written. This will be completed by 10/31/2007. It will be monitored by the Facility Director and Clinical supervisor. |
709.32(c)(4) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(4) Methods for control and accountability of drugs.
|
Observations
Based on a review of the project's policy manual and clients' medication administration records (MAR's), the facility failed to ensure that clients signed the MAR indicating the self administration or rejection of prescribed medication. The project's policy manual stated that clients will sign the MAR's acknowledging the self administration or rejection of prescribed medication. A review of the MAR's indicated that staff members were signing the MAR's indicating whether or not the client self administered the prescribed medication, but no client signature was documented.
|
Plan of Correction
The residential staff monitoring medication failed to follow the procedure. In order to address this issue, the Residential Supervisor and co-training cooordinator will conduct a group training at New Start II on 11/2/2007 for all staff who monitor medication. In addtion, the Res. Supervisor and Cl. Supervisor will review med logs monthly and identify any staff person needed one to one training. The Res. Supervisor will continue to review the medication logs weekly and report findings to the facility director. |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
|
Observations
Based on a review of the project's policy manual and sample medication inventories, the facility failed to document an accurate account of all sample medications provided by the facility's psychiatrist. A review of the project's policy manual stated that an inventory for sample medication would be conducted on a monthly basis by the residential counselor and that the residential counselor would submit the documented inventory count to the clinical supervisor for approval. In addition, the policy stated that client medications would be counted each month by the residential counselor. The sample medication inventory indicated that inventories were only documented monthly for medications previously provided and not for additional sample medications presented by the psychiatrist. This resulted in an inaccurate count for all sample medication. In addition, the facility failed to document in the inventory log when the psychiatrist prescribed a sample medication for a client from the in-house inventory.
|
Plan of Correction
The sample medication log was drated and utilized without an initial count, it has since been revised to include an initial count, medications received and disposal dates for expired medications. Residential Team Leaders will be responsible for documenting all sample medication inventory as it comes into the facility. The Res. Supervisor will inspect the log monthly for accuracy and forward the monthly reports to the Clinical supervisor for inclusion in the quarterly reports. |
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 client records and staff interview, the facility failed to ensure that complete physical examinations were documented in two of two records reviewed, #1 and 2. The physical examination form failed to include the client's general appearance in two of two client records reviewed, #1 and 2. The physician's impressions specific to the client were not documented in one record reviewed, #1.
|
Plan of Correction
The physical examinations were not completed as outlined for general appearance and physician impressions. The Resourece Manager in conjuction with the facility director will meet with the doctor and his office manager on 10/25/2007 to discuss the requirements and expectations for completing the physical forms. After the meeting the resurce manager will review all physicials and return any to the docot that do not have an clinical impression, general appearance or anything that is incomplete or incorrectley completed. The resurce manager will report any concerns to the director as needed. |
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.
|
Observations
Based on a review of client records, the facility failed to document a complete treatment plan update in one of two records reviewed, #2. The treatment plan update failed to include an assessment of the client's progress in relationship to the stated goals of the comprehensive treatment plan.
|
Plan of Correction
The threapist had completed the update but failed to include the assessment of goals. The Treatment plan form will be revisied to become more user friendly, in addition the clinical supervisor and members of the clinical audit team will review the updates for all expected components. During the bi-monthly review the clincal supervisor will assure that the therapists are completing the assessments.In addition New Start II staff will be trained on clinical paperwork documentation on 10/17/2007. |
709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
|
Observations
Based on a review of client records, the facility failed to document work therapy as a goal in the treatment and rehabilitation plan in two of two records reviewed, #1 and 2. The documentation of work done by the client failed to demonstrate that the work was an integral part of the client's treatment and rehabilitation plan.
|
Plan of Correction
Although staff realize that work therapy must be relevant to client needs and the goals documented they have not done it up to the required standard. The Facility Director and Cl. Supervisor have completed new work therapy goal forms that have all needed components and show clear integration on the rehabilitation goeal. These forms will be completed by the life skills counselor and will be monitored and signed by the clinical supervisor on a monthly basis. The completion date will be 11/12/2007. The training was conducted on 11/2/07. |