INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 11-12, 2012 by staff from the Division of Drug and Alcohol 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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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on the review of personnel records, the facility failed to document direct observation supervision, for counselor assistants.
The findings include:
Six personnel records were reviewed July 11, 2012. Of the six records reviewed, one was identified as a counselor assistant, specifically personnel record # 6. Counselor assistants are required to receive one hour of direct observation supervision per week. The facility did not document direct observation in personnel record # 6.
The documented supervision notes in personnel record # 6 did not indicate that at least one hour per week of direct observation was occurring.
An interview with the facility director on July 11, 2012 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document that fire extinguisher training was provided upon employment.
The findings include:
Five personnel records requiring documentation of fire extinguisher training were reviewed on July 11, 2012. The facility did not document that fire extinguisher training was provided upon employment in personnel records # 3, 4, and 5.
Personnel # 3 was hired on 6/7/12, but verification of this training was not documented at the time of review.
Personnel # 4 was hired on 6/13/12, but verification of this training was not documented at the time of review.
Personnel # 5 was hired on 6/15/12, but verification of this training was not documented at the time of review.
An interview with the facility director on July 11, 2012 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on the review of personnel records, the facility failed ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies
The findings include:
Five personnel records requiring documentation of emergency training were reviewed on July 11, 2012. The facility did not document that emergency training was provided prior to personnel working a shift in personnel records # 3, 4 and 5.
Personnel # 3 was hired on 6/7/12, but verification of this training was not documented at the time of review.
Personnel # 4 was hired on 6/13/12, but verification of this training was not documented at the time of review.
Personnel # 5 was hired on 6/15/12, but verification of this training was not documented at the time of review.
An interview with the facility director on July 11, 2012 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to document a physical examination within seven days from admission.
The findings include:
Six client records requiring physical examinations were reviewed on July 12, 2012, specifically records # 1, 2, 3, 4, 5 and 6. The facility did not document a physical examination within seven days from admission in client records # 1, 3, 4 and 5.
Client # 1 was admitted on 4/17/12, but the physical examination was dated 7/3/12.
Client # 3 was admitted on 4/19/12, but the physical examination was dated 5/17/12.
Client # 4 was admitted on 6/7/12, but the physical examination was dated 6/26/12.
Client # 5 was admitted on 4/19/12, but client # 5 ' s record did not contain a physical examination.
An interview with the facility director on July 12, 2012 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |
709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document treatment plans that included type and frequency of treatment and rehabilitation services.
The findings include:
On July 12, 2012, treatment plans in four client records were reviewed for documentation type and frequency of treatment and rehabilitation services, specifically in records # 1, 2, 3 and 4. The facility did not document treatment plans to include type and frequency of treatment and rehabilitation services in client records # 1, 2, 3 and 4.
Client # 1 was admitted on 4/17/12. The treatment plan in client # 1 ' s record dated 5/7/12 did not include type and frequency of treatment and rehabilitation services.
Client # 2 was admitted on 4/17/12. The treatment plan in client # 2 ' s record dated 5/7/12 did not include type and frequency of treatment and rehabilitation services.
Client # 3 was admitted on 4/19/12. The treatment plan in client # 3's record dated 5/9/12 did not include type and frequency of treatment and rehabilitation services.
Client # 4 was admitted on 6/7/12. The treatment plan in client # 4's record dated 6/27/12 did not include type and frequency of treatment and rehabilitation services.
An interview with the facility director on July 12, 2012 confirmed the findings.
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Plan of Correction
This facility does not file electronically, a Plan of Correction is on file with the Department of Health. |