INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 6, 2022 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Resources For Human Development, 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, conducted at approximately 9:30 am, the facility failed to store all trash, garbage and rubbish in noncombustible covered containers that prevent the penetration of insects and rodents. At the time of the inspection, the outside trash dumpsters, located beside the building, did not have their lids closed.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
All staff were retrained on the requirement that the lids remain closed on the dumpster.
The Assistant Program Manager is responsible for checking the dumpster at the beginning and end of each work day to assure that the lids are closed.
The Assistant Program Manager assigns a weekend staff member to assure that the lids on the dumpster are closed over the weekend. |
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 must 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 the specific information to be disclosed on consent to release information forms in three of seven client records reviewed.
Client #2 was admitted December 29, 2021 and was active at the time of inspection. The release of information form to an emergency contact was signed and dated by the client and witness on December 29, 2021, but the release form failed to document the specific information to be disclosed.
Client #4 was admitted December 16, 2021 and was discharged April 6, 2022. The release of information form to an emergency contact was signed and dated by the client and witness on December 16, 2021, but the release form failed to document the specific information to be disclosed.
Client #6 was admitted December 23, 2021 and was discharged February 7, 2022. The release of information form to an emergency contact was signed and dated by the client and witness on December 23, 2021, but the release form failed to document the specific information to be disclosed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The incorrect releases of information were all completed by one staff member. That staff member has been retrained on the correct way to complete a release of information for an emergency contact.
It is the responsibility of the program director to assure that all releases of information are completed correctly. This will be accomplished during ongoing monthly chart audits. |
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 must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review client records, the facility failed to document the purpose of the disclosure on release of information forms in two of seven client records reviewed.
Client #4 was admitted December 16, 2021 and was discharged April 6, 2022. The release of information form to an emergency contact was signed and dated by the client on December 16, 2021, but the form did not document the purpose of the disclosure.
Client #6 was admitted December 23, 2021 and was discharged February 7, 2022. The release of information form to an emergency contact was signed and dated by the client on December 23, 2021, but the form did not document the purpose of the disclosure.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The incorrect releases of information were both completed by one staff member. That staff member has been retrained on the correct way to complete a release of information for an emergency contact.
It is the responsibility of the program director to assure that all releases of information are completed correctly. This will be accomplished during ongoing monthly chart audits. |