INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 8, 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 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility-submitted Staffing Requirement Facility Summary Report, the facility failed to ensure that all staff completed at least 4 hours of TB/STD and other health-related topics and a minimum of 6 hours of HIV/AIDs training within the regulatory timeframe in one of three applicable personnel records reviewed.
Employee #6 was hired as a counselor on May 31, 2021. The TB/STD training was to be completed no later than May 31, 2022. There was no documentation that the training was completed at the time of the inspection.
This is a repeat citation from the July 15, 2021 annual licensing renewal inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Clinical Director will meet with Employee #6 by 9/1/22 and review training requirements, including the necessity of keeping the camera on during the entirety of the training in order to receive credit for participating. Employee #6 took the course again and received a certificate on 7/12/22. The Director and Office Manager will conduct quarterly reviews of all employee training plans and training logs, to ensure that all staff are in compliance with regulatory requirements. The Director will be responsible for ensuring that corrective action is implemented. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of the policy and procedure manual and a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable client record reviewed.
Per the policy and procedure manual, the program will contact the participant's emergency contact when the participant leaves against facility advice.
Client #7 was admitted on September 3, 2021 and was discharged against facility advice on December 29, 2021. There was no attempted emergency contact notification documented in the record at the time of the inspection.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director will conduct a refresher review/training for our written procedure for contacting the participant's emergency contact for when a client leaves AFA with staff during the Clinical Team Meeting on 8/30/2022. The Director will review charts monthly during supervision. A quality review of all documents in chart will be done prior to completion/ discharge. |
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 must be in writing and include, but not be limited to:
(4) Dated signature of client or guardian as provided for under 42 CFR 2.14(a) and (b) and 2.15 (relating to minor patients; and incompetent and deceased patients).
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Observations
Based on a review of client records, the facility failed to document the dated signature of a client on informed and voluntary consent to release information forms in five of seven client records reviewed.
Client #1 was admitted on February 22, 2022 and was active at the time of inspection. There was a release of information form to an attorney signed by the witness on March 3, 2022; however, the dated signature of the client was not documented.
Client #2 was admitted on March 22, 2022 and was active at the time of inspection. There were release of information forms to a laboratory, a funding source, a pharmacy, and an emergency contact signed by the witness on March 22, 2022; however, the dated signature of the client was not documented on any of the forms.
Client #4 was admitted on August 24, 2021 and was discharged on February 14, 2022. There was a release of information form to a transportation service signed by the witness on September 16, 2021; however, the dated signature of the client was not documented. Additionally, there was a release of information form to another treatment facility signed by the witness on January 31, 2022; however, the dated signature of the client was not documented.
Client #5 was admitted on December 27, 2021 and was discharged on March 16, 2022. There was a release of information form to a government agency signed by the witness on January 5, 2022; however, the dated signature of the client was not documented. Additionally, there was a release of information form to a hospital signed by the witness on January 11, 2022; however, the dated signature of the client was not documented. Also, there was a release of information form to a case manager signed by the client and the witness, but client's signature was not dated.
Client #7 was admitted on September 3, 2021 and was discharged on December 29, 2021. There was a release of information form to an emergency contact signed by the witness on September 3, 2021; however, the dated signature of the client was not documented.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director will meet with the Morris Home clinical team on 8/30/2022 to review/ re-train on the workflow related to consents to ensure that all staff completing intakes review ROI/ consent with members and ensure dates and signatures are done. The current members charts have been corrected. Additionally, the Director will conduct reviews of all intake packets during supervision to ensure all consents are completed correctly. |
709.28 (c) (5) 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:
(5) Dated signature of witness.
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Observations
Based on a review of client records, the facility failed to document the dated signature of a witness on informed and voluntary consent to release information forms in four of seven client records reviewed.
Client #1 was admitted on February 22, 2022 and was active at the time of inspection. There was a release of information form to an external human service agency signed by the client on February 22, 2022; however, the dated signature of the witness was not documented.
Client #2 was admitted on March 22, 2022 and was active at the time of inspection. There was a release of information form to a medical center signed by the client on March 30, 2022; however, the dated signature of the witness was not documented.
Client #4 was admitted on August 24, 2021 and was discharged on February 14, 2022. There was a release of information form to another treatment provider signed by the client on September 14, 2021; however, the dated signature of the witness was documented on September 7, 2021.
Client #5 was admitted on December 27, 2021 and was discharged on March 16, 2022. There was a release of information form to a case manager signed by the client and witness, but the witness signature was not dated.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director will meet with the Morris Home clinical team on 8/30/2022 to review workflow related to consents to ensure that all staff completing intakes ensure members date their signatures. Additionally, the Director will conduct quality reviews during supervision of all intake packets to ensure all consents are completed correctly.
Active clients #1 and #2 forms were corrected an updated following the initial audit. |
709.30 LICENSURE Client Rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
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Observations
Based on a review of the policy and procedure manual, the facility failed to include, in their written policies and procedures on client rights, that the project may not discriminate in the provision of services on the basis of sex and color.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director amended our policies and procedures on client rights to include that project may not discriminate on the basis of sex and color on 8/1/2022. These changes will be reviewed with the Clinical Team meeting on 8/30/22. |
709.30 (2) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(2) The project may not discriminate in the provision of services on the basis of age, race, creed, sex, ethnicity, color, national origin, marital status, sexual orientation, handicap or religion.
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Observations
Based on a review of client records, the facility failed to include, on the client-signed written acknowledgement form, that the client had been informed of their right that the project may not discriminate in the provision of services on the basis of creed, color, and marital status in seven of seven client records reviewed.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
The Director amended our intake paperwork on 8/1/2022 to include on the client signed written acknowledgement form that all clients were informed of their right that the project may not discriminate in the provision of services on the basis of creed, color, and marital status. This change will be communicated to the clinical team at the 8/30/22 Clinical Team Meeting. |