INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. 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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705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to store all trash, garbage and rubbish in covered containers.
The findings include:
A physical plant inspection was conducted on June 7, 2011 between approximately 1:00 PM and 2:00 PM. The facility was required to store all trash, garbage and rubbish in covered containers. At the time of inspection, the trash dumpster was overflowing with trash. The dumpster's lids could not be closed due to the excessive amount of trash in the dumpster.
An interview with the facility director on June 7, 2011 at approximately 2:00 PM confirmed the findings.
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Plan of Correction
Office Manager will contact waste management company to ensure waste pick up twice a week. To avoid dumster overflowing with trash, a lock will be put on dumster to ensure that dumster lids can close. Director will monitor for ongoing compliance. This corrective action plan will be in effect July 1, 2011. |
705.6 (2) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to provide soap in each bathroom.
The findings include:
A physical plant inspection was conducted on June 7, 2011 between approximately 1:00 PM and 2:00 PM. The facility was required to provide an operable soap dispenser in each bathroom.
One of the two bathrooms on the second floor did not have soap at the time of inspection.
The bathroom on the third floor did not have soap at the time of inspection.
An interview with the facility director on June 7, 2011 at approximately 2:00 PM confirmed the findings.
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Plan of Correction
1. The ADL Counselor will complete a daily check to verify that every bathroom has a properly operating soap dispenser.
2. Director will monitor all bathrooms for on-going compliance. This corrective action plan will go into effect July 1, 2011. |
705.7 (b) (3) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(3) Clean all eating, drinking and cooking utensils and all food preparation areas after each usage and store the utensils in a clean enclosed area.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to store all eating utensils in an enclosed area when not in use.
The findings include:
A physical plant inspection was conducted on June 7, 2011 between approximately 1:00 PM and 2:00 PM. The facility was required to store eating utensils in an enclosed area when not in use. At the time of inspection, the forks and knives were stored uncovered on a kitchen shelf behind a curtain.
An interview with the facility director on June 7, 2011 at approximately 2:00 PM confirmed the findings.
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Plan of Correction
Effective July 1, 2011 the program will supply a covered container to store forks and knives. The ADL Counselor will monitor kitken to ensure utensils remain in an enclosed area when not in use. Director will monitor storage of all utensils for ongoing compliance. |
705.10 (c) (3) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to ensure the annual inspection and approval of all fire extinguishers by the local fire department or fire extinguisher company.
The findings include:
A physical plant inspection was conducted on June 7, 2011 between approximately 1:00 PM and 2:00 PM. The facility ' s fire suppression system in the in the kitchen was not inspected by the local fire department or fire extinguisher company for the 2010 year. The inspection tag on the kitchen fire suppression system stated in had not been inspected since December 2009.
An interview with the facility director on June 7, 2011 at approximately 2:00 PM confirmed the findings.
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Plan of Correction
Effective June 13, 2011, Office Manager contacted Kistler-O'Brien Fire Protection Co. and recieved a copy of the updated fire suppression system inspection document for the year 2010. Moving forward the Director will ensure that all fire extinguishers and suppression systems are inspected and tagged yearly. |
709.28(c)(4) 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:
(4) Dated signature of client or guardian.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document a dated signature of the client on release of information forms in four of six client records.
The findings include:
On June 7, 2011, consent to release information forms were reviewed in six client records, specifically client records # 1, 2, 3, 4, 5 and 6. The facility did not document a dated signature of the client on release of information forms in client records # 1, 2, 3 and 4.
Client record # 1 contained two consent forms releasing client information to government agencies, but the consent forms did not include a dated signature of the client. The forms were signed by the client but not dated.
Client record # 2 contained two consent forms releasing client information to government agencies, and five consent forms releasing client information to apartment rental offices. None of these consent forms included a dated signature of the client. The forms were signed by the client but not dated.
Client record # 3 contained five consent forms releasing client information to government agencies, one consent form releasing client information to an insurance company, one consent form releasing client information to a dentist, and one consent form releasing client information to a drug store. None of these consent forms included a dated signature of the client. The forms were signed by the client but not dated.
Client record # 4 contained a consent form releasing client information to a transitional housing program, but the consent form did not include a dated signature of the client. The form was signed by the client but not dated.
An interview with the facility director on June 7, 2011 confirmed the findings.
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Plan of Correction
Effective July 1, 2011 the Director will train all staff on how to properly complete informed and voluntary consents. Director will review clinical charts to ensure that all consents forms have a dated signature of the client. |
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 and an interview with the facility director, the facility failed to document a physical examination within seven days from admission, as per facility policy, in five of six client records.
The findings include:
On June 7, 2011, physical examinations were reviewed in six client records, specifically records # 1, 2, 3, 4, 5 and 6. The facility did not document physical examinations within seven days from admission in client records # 1, 2, 3, 5 and 6.
The facility ' s policy titled "Intake and Admission Procedure" states:
Within the first week of admission the client will:
1.Complete medical self assessment
2.Have a physical examination within 7 days from admission
3.Participate in creating preliminary treatment plan
4.Meet with therapist to begin psycho-social history
5.Tuberculosis test within 7 days from admission
Client # 1 was admitted to the facility on 2/23/11, but the client ' s record did not contain a physical examination.
Client # 2 was admitted to the facility on 2/3/11, but the client ' s record did not contain a physical examination.
Client # 3 was admitted to the facility on 4/11/11, but the client ' s record did not contain a physical examination.
Client # 5 was admitted to the facility on 10/12/10, but the physical examination was dated 10/21/10.
Client # 5 was admitted to the facility on 8/30/10, but the physical examination was dated 9/13/10.
An interview with the facility director on June 7, 2011 confirmed the findings.
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Plan of Correction
Upon addmission ADL Counselor will call and obtain an appointment to ensure that all clients receive a phsyical examination within seven days of addmission. All physical examination documents will be filed in the client's clinical records. Director will monitor clinical charts for ongoing compliance. This corrective action plan will be in effect as of July 1, 2011. |