INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Program Licensure, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 2, an abbreviated on-site inspection, conducted on March 15, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Not all regulations were reviewed, the remainder of the regulations were reviewed during Part 1.
Based on the findings of Part 2, an abbreviated 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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705.7 (b) (2) 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:
(2) Clean and disinfect food preparation areas and appliances following each prepared meal.
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Observations
Based on a physical plant inspection, the facility failed to clean and disinfect all food preparation areas and appliances following each prepared meal. At approximately 10:10 AM on March 15, 2021, the range top and backsplash were covered with a large buildup of grease.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
A professional cleaning service was contacted to perform a thorough cleaning of the range top and backsplash.
It is the responsibility of the Assistant Program Manager to assure that the kitchen is cleaned appropriately after each meal.
Going forward, the director will conduct a monthly inspection of the kitchen to assure that all appliances are maintained in a clean and safe manner. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant inspection, the facility failed to ensure that all facility heaters were permanently mounted or installed. At approximately 10:05 AM on March 15, 2021, a space heater was found in a third-floor bedroom and a space heater was found in a first floor office.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The space heaters have been removed from the facility. The heater in the office was brought in by a staff member. That staff member was instructed to take the heater home.
Going forward, room checks will include assuring that there are no space heaters in the facility. This will be the responsibility of the Assistant Manager. |
709.28 (c) 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.
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent to release information form prior to the disclosure of information in four of seven client records reviewed.
Client # 1 was admitted on August 12, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 2 was admitted on August 20, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 3 was admitted on July 20, 2020 and was still active at the time of the inspection. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no consent to release information form signed by the client documented in the record prior to any of the disclosures.
Client # 4 was admitted on January 2, 2020 and was still discharged on March 30, 2020. There was a release of information form to the funding source, signed and dated by the client and witness on January 9, 2020. The effective dates on the form were January 9, 2020 through January 8, 2020; therefore, the release of information form was not valid. There was evidence of disclosures to the funding source during the client's treatment episode; however, there was no valid consent to release information form signed by the client documented in the record prior to any of the disclosures.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Consents to release information are completed during intake. The release for client #4 contained an error in that the date was written incorrectly. The releases for the other noted residents had been completed but had not been filed due to a delay in that process due to COVID-19.
It is the responsibility of the Resource Coordinator to complete all releases of information and place the entire intake packet in the resident's chart. Going forward, the director will be responsible for assuring that all documents are completed correctly and filed in a timely manner. |
709.28 (c) (1) 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:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based on a review of client records, the facility failed to document the name of the person, agency, or organization to whom the disclosure was to be made to on release of information forms in one of seven client records reviewed.
Client # 5 was admitted on January 9, 2020 and was discharged on September 11, 2020. The client record contained a release of information form for an emergency contact that was signed and dated by the client on January 20, 2020; however the form did not document the name of the person, agency, or organization to whom the disclosure was to be made to.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Consents to release information are completed during intake. The name of the emergency contact for client #5 was mistakenly left blank.
It is the responsibility of the Resource Coordinator to complete all releases of information.Going forward, the director will be responsible for assuring that all documents are completed correctly. |
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 the client on release of information forms in one of seven client records reviewed.
Client # 5 was admitted on January 9, 2020 and was discharged on September 11, 2020. The record contained release of information forms to the funding source and the pharmacy that were signed by the client; however, both release forms failed to include the date the forms were signed by the client.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Consents to release information are completed during intake. The dates for client #5 were mistakenly left blank.
It is the responsibility of the Resource Coordinator to complete all releases of information. Going forward, the director will be responsible for assuring that all documents are completed completely and accurately. |
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 the witness on release of information forms in one of seven client records reviewed.
Client # 5 was admitted on January 9, 2020 and was discharged on September 11, 2020. The record contained release of information forms to the funding source and the pharmacy that were signed by the client; however, both of the forms failed to document the dated signature of the witness.
This finding was reviewed with facility staff during the licensing inspection.
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Plan of Correction
Consents to release information are completed during intake. The Resource Coordinator mistakenly failed to sign as witness for Client #5.
It is the responsibility of the Resource Coordinator to complete all releases of information. Going forward, the director will be responsible for assuring that all documents are completed completely and accurately. |
709.28 (d) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client record.
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Observations
Based on a review of client records, the facility failed to document that a copy of a client consent was offered to the client in each release of information form in two of seven client records reviewed.
Client # 4 was admitted on January 2, 2020 and was discharged on March 30, 2020. All of the release of information forms in the record were signed by the client and witness on January 9, 2020, but there was no documentation that a copy of the consents were offered to the client.
Client # 5 was admitted on January 9, 2020 and was discharged on September 11, 2020. All of the release of information forms were signed by the client and witness on January 20, 2020, but there was no documentation that a copy of the consents were offered to the client.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Consents to release information are completed during intake. The field in which the client accepts or rejects a copy for client #5 was mistakenly left blank.
It is the responsibility of the Resource Coordinator to complete all releases of information.Going forward, the director will be responsible for assuring that all documents are completed completely and accurately. |
709.51(b)(3)(i) LICENSURE Medical histories
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(i) Medical history.
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Observations
Based on a review of client records, the facility failed to document a medical history of the client during their intake process in four of seven client records reviewed.
Client # 4 was admitted on January 2, 2020 and was discharged on March 30, 2020. The client record did not document a medical history of the client at the time of the inspection.
Client # 5 was admitted on January 9, 2020 and was discharged on September 11, 2020. The client record did not document a medical history of the client at the time of the inspection.
Client #6 was admitted on November 4, 2019 and was discharged on August 12, 2020. The client record did not document a medical history of the client at the time of the inspection.
Client #7 was admitted on October 31, 2019 and was discharged on July 10, 2020. The client record did not document a medical history of the client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Medical history is documented as part of the biopsychosocial summary completed within two weeks of admission. The therapist is responsible for completing the biopsychosocial.
All four of the noted residents had their biopsychosocial summaries completed by the full time clinician, who is no longer employed at the facility. That clinician was working through telehealth and left hard copies of each to be filed. They could not be located.
Going forward, once the pandemic eases and the therapists are back on site, the therapist will continue to be responsible for completing and filing the biopsychosocial summaries. The director will be responsible for filing them until that time.
The director will conduct monthly audits of charts to assure that all biopsychosocial assessments have been completed and filed correctly and in a timely manner. |
709.51(b)(3)(ii) LICENSURE Drug & Alcohol History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(ii) Drug or alcohol history, or both.
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Observations
Based on a review of client records, the facility failed to document a drug and/or alcohol history of the client during their intake process in four of seven client records reviewed.
Client # 4 was admitted on January 2, 2020 and was discharged on March 30, 2020. The client record did not document a drug and/or alcohol history of the client at the time of the inspection.
Client # 5 was admitted on January 9, 2020 and was discharged on September 11, 2020. The client record did not document a drug and/or alcohol history of the client at the time of the inspection.
Client #6 was admitted on November 4, 2019 and was discharged on August 12, 2020. The client record did not document a drug and/or alcohol history of the client at the time of the inspection.
Client #7 was admitted on October 31, 2019 and was discharged on July 10, 2020. The client record did not document a drug and/or alcohol history of the client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Drug and/or alcohol history is documented as part of the biopsychosocial summary completed within two weeks of admission. The therapist is responsible for completing the biopsychosocial.
All four of the noted residents had their biopsychosocial summaries completed by the full time clinician, who is no longer employed at the facility. That clinician was working through telehealth and left hard copies of each to be filed. They could not be located.
Going forward, once the pandemic eases and the therapists are back on site, the therapist will continue to be responsible for completing and filing the biopsychosocial summaries. The director will be responsible for filing them until that time.
The director will conduct monthly audits of charts to assure that all biopsychosocial assessments have been completed and filed correctly and in a timely manner. |
709.51(b)(3)(iii) LICENSURE Personal History
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(3) Histories, which include the following:
(iii) Personal history.
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Observations
Based on a review of client records, the facility failed to document a personal history of the client during their intake process in four of seven client records reviewed.
Client # 4 was admitted on January 2, 2020 and was discharged on March 30, 2020. The client record did not document a personal history of the client at the time of the inspection.
Client # 5 was admitted on January 9, 2020 and was discharged on September 11, 2020. The client record did not document a personal history of the client at the time of the inspection.
Client #6 was admitted on November 4, 2019 and was discharged on August 12, 2020. The client record did not document a personal history of the client at the time of the inspection.
Client #7 was admitted on October 31, 2019 and was discharged on July 10, 2020. The client record did not document a personal history of the client at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Personal history is documented as part of the biopsychosocial summary completed within two weeks of admission. The therapist is responsible for completing the biopsychosocial.
All four of the noted residents had their biopsychosocial summaries completed by the full time clinician, who is no longer employed at the facility. That clinician was working through telehealth and left hard copies of each to be filed. They could not be located.
Going forward, once the pandemic eases and the therapists are back on site, the therapist will continue to be responsible for completing and filing the biopsychosocial summaries. The director will be responsible for filing them until that time.
The director will conduct monthly audits of charts to assure that all biopsychosocial assessments have been completed and filed correctly and in a timely manner. |
709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation, as part of their intake process, in four of seven client records reviewed.
Client # 4 was admitted on January 2, 2020 and was discharged on March 30, 2020. The client record did not document a psychosocial evaluation at the time of the inspection.
Client # 5 was admitted on January 9, 2020 and was discharged on September 11, 2020. The client record did not document a psychosocial evaluation at the time of the inspection.
Client #6 was admitted on November 4, 2019 and was discharged on August 12, 2020. The client record did not document a psychosocial evaluation at the time of the inspection.
Client #7 was admitted on October 31, 2019 and was discharged on July 10, 2020. The client record did not document a psychosocial evaluation at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Each resident's psychosocial evaluation is documented as part of the biopsychosocial summary completed within two weeks of admission. The therapist is responsible for completing the biopsychosocial.
All four of the noted residents had their biopsychosocial summaries completed by the full time clinician, who is no longer employed at the facility. That clinician was working through telehealth and left hard copies of each to be filed. They could not be located.
Going forward, once the pandemic eases and the therapists are back on site, the therapist will continue to be responsible for completing and filing the biopsychosocial summaries. The director will be responsible for filing them until that time.
The director will conduct monthly audits of charts to assure that all biopsychosocial assessments have been completed and filed correctly and in a timely manner. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to review and update treatment and rehabilitation plans at least every thirty days in three of seven client records reviewed.
Client # 1 was admitted on August 12, 2020 and was still active at the time of the inspection. A treatment plan update was completed on January 28, 2021 and an update was due no later than February 28, 2021; however, there was no update completed at the time of the inspection.
Client # 3 was admitted on July 20, 2020 and was still active at the time of the inspection. A treatment plan update was completed on November 28, 2020 and an update was due no later than December 28, 2021; however, the update was completed on January 22, 2021.
Client #7 was admitted on October 31, 2019 and was discharged on July 10, 2020. A treatment plan update was completed on February 23, 2020 and an update was due no later than March 23, 2020; however, the update was completed on April 9, 2020. Additionally, a treatment plan update was completed on April 9, 2020 and an update was due no later than May 9, 2020; however, the update was completed on June 4, 2020.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Treatment plans were completed on time. However, during the pandemic, with therapists working remotely, the program fell short on filing all paperwork in a timely manner.
Clinical staff will continue to be responsible for completing and filing treatment plans.
Going forward, the director will conduct monthly chart reviews to assure that all documentation is completed and filed in a timely manner. |
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 document a complete client record, which is to include case consultation notes, in seven of seven client records reviewed.
Client # 1 was admitted on August 12, 2020 and was still active at the time of the inspection. The client record did not document case consultation notes at the time of the inspection.
Client # 2 was admitted on August 20, 2020 and was still active at the time of the inspection. The client record did not document case consultation notes at the time of the inspection.
Client # 3 was admitted on July 20, 2020 and was still active at the time of the inspection. The client record did not document case consultation notes at the time of the inspection.
Client # 4 was admitted on January 2, 2020 and was discharged on March 30, 2020. The client record did not document case consultation notes at the time of the inspection.
Client # 5 was admitted on January 9, 2020 and was discharged on September 11, 2020. The client record did not document case consultation notes at the time of the inspection.
Client #6 was admitted on November 4, 2019 and was discharged on August 12, 2020. The client record did not document case consultation notes at the time of the inspection.
Client #7 was admitted on October 31, 2019 and was discharged on July 10, 2020. The client record did not document case consultation notes at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case consultation for the noted residents who are still active in the program (numbers 1 & 3) will be completed on 4/1/2021.
Going forward, case consultations will be documented during reviews with funders, as all dimensions are discussed during those meetings and multiple people are present.
During monthly chart reviews, the director will assure that case consults are completed and documented in the chart for each resident. |
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 a review of client records, the facility failed to document a complete client record, which is to include follow-up information, in four of four applicable client records reviewed.
Client # 4 was admitted on January 2, 2020 and was discharged on March 30, 2020. The client record did not document follow-up information at the time of the inspection.
Client # 5 was admitted on January 9, 2020 and was discharged on September 11, 2020. The client record did not document follow-up information at the time of the inspection.
Client #6 was admitted on November 4, 2019 and was discharged on August 12, 2020. The client record did not document follow-up information at the time of the inspection.
Client #7 was admitted on October 31, 2019 and was discharged on July 10, 2020. The client record did not document follow-up information at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Resource Coordinator is responsible for documenting follow-up contacts after a resident has been discharged from the program. While the follow-ups did take place, they were not documented.
The Resource Coordinator has been retrained to understand the need to document follow-up contacts.
The director will review monthly all recently closed charts to assure that follow-up contacts are completed and documented in a timely fashion. |