INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 3-4, 2013 by staff from the 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(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's policy and procedure manual, the facility failed to documented when the overall plan was completed.
The findings include:
The policy and procedure manual was reviewed on June 3, 2013. The staff development policy, states that the overall plan will be completed by July 30 of each fiscal year. The overall plan was reviewed and documented but failed to document when the plan was completed.
An interview with facility staff in June 4, 2013 confirmed the findings.
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Plan of Correction
The overall annual plan has been reviewed by all of the Family House/Womenspace Program Directors including the director of Family House on June 28, 2013. The completed document now has the date it was completed and each staff now will be required to sign and date the overall training plan each year. Each year the Director will ensure that the plan has date it was completed and all staff will sign and dated when the receive it and this will be done by 7/30/2013 |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of staff training plans and the Staffing Requirements Facility Summary Report, the facility failed to document when training plans were developed for twenty of twenty staff members reviewed.
The findings include:
The facility policy, states that staff training plans will be developed by July 30 of each training year
The staff training plans and the Staffing Requirements Facility Summary Report (SRFSR)were reviewed on June 3, 2013. Four of the twenty staff had training plans documented with no dates of when they were completed, specifically, #1, 2, 3 and 4. Also, a review of the SRFSR identified 16 support staff that did not have a staff training plan for the 2012/2013 training year.
An interview with the facility director on June 4, 2013 confirmed the findings.
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Plan of Correction
Individual training plan for # 1 will be completed by # 1 and will include a date and a signature and will be available in his personnel file. Program Director from Family House will make sure #1 has the form that needs to be completed. He will have his assistant place form in his file once form is completed and it will completed by July 30th, 2013. Individual training plans will be completed by #2, 3, and 4 and all 16 direct care staff and any additional staff hired after July 1, 2013. Program Director will assure that the all staff complete the individual training plans and they will be signed and dated by the staff completing form and that staff person supervisor by July 30th, 2013.Program Director Will assure that the from are done correctly and on time with signatures and dates.
Charts will be checked by office manager to make form is filed in the staff chart and report findings to the Program Director.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill log, the facility failed to document the completion of monthly unannounced fire drills.
The findings include:
The fire drill log was reviewed on June 3, 2013 for the time period of June 2012 to May 2013. Documentation of fire drills was missing for the months of June 2012, October 2012, December 2012, March 2013 and April 2013.
An interview with facility staff on June 4, 2013 confirmed the findings.
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Plan of Correction
Assistant Director will meet with the ADL/Resource Coordinator monthly to assure that the appropriate ADL staff has a unannounced fire drill completed at least once a month. |
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.
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Observations
Based on a review of the fire drill log, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
The Fire drill log was reviewed on June 3, 2013 for the period of June 2012 to May 2013 to ensure that the facility conducted fire drills during sleeping hours at least once every six months. During that time frame, the facility documented only one fire drill during sleeping hours, February 23, 2013.
An interview with facility staff on June 4, 2013 confirmed the findings.
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Plan of Correction
Assistant Director will meet with the ADL/Resource Coordinator to assure the overnight ADL staff conducts an unannounced asleep fire drill at least once every six months. |
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 shall 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 what specific information was to be disclosed on the consent to release form in six of eight records reviewed.
The findings include
Eight client records were reviewed on June 4, 2013. Six of the eight client records contained consent to release information forms that failed to document the specific information to be disclosed, specifically records, #1, 2, 3, 4, 5 and 6. An interview with facility staff on June 4, 2013 confirmed the findings.
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Plan of Correction
Unit Director will train Therapist and ADL staff, Office Manager staff persons, who are responsible for completing the consent to release information forms paying special attention to and making sure that what information is to be disclosed is specified on all release of information forms. This training will be completed by 6/28/2013. Unit Director will review all forms for completeness of information to be disclosed is specific identified on each release. |
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 shall 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 for the disclosure on the consent to release forms in six of eight records reviewed.
The findings include
Eight client records were reviewed on June 4, 2013. Six of the eight client records contained consent to release information forms that failed to document the purpose for the disclosure of information specifically records, #1, 2, 3, 4, 5 and 6. An interview with facility staff on June 4, 2013 confirmed the findings.
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Plan of Correction
Unit Director will train Therapist and ADL staff and Office Manager staff who will be responsible for completing the consent to release information from paying special attention to making sure that the purpose of the disclosure is clearly documented on all consent to release information forms. This training will be completed by June 28, 2013. Unit Director will review all forms for completeness of the purpose of what is being disclosed is indicated on all forms on an ongoing basis. |
709.53(a)(8) LICENSURE Case Consultation Notes
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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to include the disposition of the case consultation in six of eight client records reviewed.
The findings include:
Eight client records were reviewed on June 4, 2013. The case consultation is to include the date of the consult, staff members present during the consult, summary of the client's progress in treatment and the disposition. The following client records didn't include the disposition on the case consults, #1, 2, 3, 4, 5 and 6.
Client # 1 was admitted on January 11, 2013. There were several case consults documented for client #1's record, 1/15, 1/22, 1/31, 2/7, 2,17, 2,19, 2/26, 3/5, 3/26, 4/9, 4/2, 4/16, 4/23, 4/30, 5/7, 5/14, 5/21 and 5/28. The case consults failed to include the disposition.
Client # 2 was admitted on March 6, 2013. There were several case consults documented for client #2's record, 3/19, 3/26, 4/2, 4/9, 4/16, 4/30, 5/7, 5/14, 5/21 and 5/28. The case consults failed to include the disposition.
Client # 3 was admitted on March 28, 2013. There were several case consults documented for client #3's record, 4/2, 4/9, 4/16, 4/23, 4/30, 5/7, 5/14, 5/21 and 5/28. The case consults failed to include the disposition.
Client # 4 was admitted on March 8, 2013. There were several case consults documented for client #4's record, 3/9, 3/26, 4/2, 4/9, 4/16, 4/23, 4/30, 5/7, 5/14, 5/21 and 5/22. The case consults failed to include the disposition.
Client # 5 was admitted on November 2, 2012 and discharged on April 29, 2013. There were several case consults documented for client #5's record, 11/6, 11/13, 11/20, 11/29, 12/4, 12/11, 12/19, 1/3, 1/9, 1/15, 1/23, 1/31, 2/7, 2/12, 2/19, 2/26, 3/5, 3/19, 3/26, 4/2, 4/9, 4/16 and 4/23. The case consults failed to include the disposition.
Client # 6 was admitted on January 11, 2013 and discharged on April 17, 2013. There were several case consults documented for client #6's record, 11/29, 12/4, 12/11, 12/14, 12/27, 1/3, 1/9, 1/15, 1/22, 1/31, 2/5, 2/12, 1/31, 2/5, 2/12, 2/13, 2/19, 2/26, 3/5, 3/19, 3/26, 4/2, 4/9 and 4/16. The case consults failed to include the disposition.
An interview with facility staff on June 4, 2013 confirmed the findings.
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Plan of Correction
Unit Director will make sure that on the case consultation forms there is a space for the staff member to record the disposition. The disposition will be discussed and then documented on the case consultation form. This will start in our July 9, 2013 case consultation meeting for all of the women. |
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.
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Observations
Based on client record review, the facility failed to document a follow up attempt in two of four records reviewed
The findings include:
The facility policy states that follow up will be attempted within seven days for referrals, and 30 days for all others
Eight client records were reviewed on June 4, 2013. Four of the eight client records reviewed required documentation of follow-up information, specifically records, #5, 6, 7 and 8. The facility failed to document a follow-up in client records #5 & 7.
Client #5 was admitted on November 2, 2012 and discharged on April 29, 2013. The follow-up should have been documented by May 2, 2013. At the time of the inspection there was no documentation of a follow-up attempt in client record #5.
Client #7 was admitted on August 10, 2012 and discharged on January 3, 2013. The client was referred and had an appointment on January 7, 2013. The facility had seven days from the day of the appointment to conduct a follow-up inspection. The facility conducted the follow-up on January 17, 2013 ten days from the required 7 days in client record #7.
An interview with facility staff on June 4, 2013 confirmed the findings.
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Plan of Correction
The Lead Therapist will be responsible for completion of a follow up contacts within seven days for all referrals and follow up within 30 days for all others. Lead Therapist will make sure to document her follow up on the correct form .
Program Director will supervisor Lead Therapist to assure that the follow ups attempt are complete in the allotted time frame. |