INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, RHD / New Start II, 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 Staffing Requirement Facility Summary Report, the facility failed to ensure all staff completed the mandatory 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health topics training within the regulatory time frame in one of four personnel records reviewed.
Employee #3 was hired as a counselor on January 18, 2023. The HIV/AIDS training and the TB/STD and other health topics training were due to be completed no later than January 18, 2024. The employee completed the HIV/AIDS training on May 10, 2024, which was past the one-year timeframe for the position. Additionally, there was no documentation in the record that the TB/STD and other health topics training was completed as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Employee #3 took the TB/STD training on 05/17/2024. When a new employee is hired, as part of their new hire orientation, their supervisor will register them for all required DDAP trainings. Program Director will audit employee charts quarterly for training compliance. |
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, the facility failed to ensure there was an operable soap dispenser in each bathroom.
The physical plant inspection was conducted between 12:45PM and 1:15PM and at the time of the inspection, both the first-floor bathroom and the second-floor bathroom did not have a functional soap dispenser.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Operable soap dispensers were placed in all bathrooms on 05/14/2024. Direct Care staff on each shift will ensure dispensers have soap and are in working order. Direct Care staff will refill soap as needed and will report to their supervisor if repairs or new equipment is needed. Residential Manager will purchase supplies as needed. |
705.6 (6) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on a physical plant inspection, the facility failed to provide toilet paper at each toilet at all times.
The physical plant inspection was conducted between 12:45PM and 1:15PM and at the time of the inspection, there was no toilet paper in the toilet stalls of both the first-floor bathroom and the second-floor bathroom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Toilet paper was placed in each bathroom upon the conclusion of the exit interview.
Direct Care staff will check bathrooms during hourly rounds to ensure toilet paper is in each bathroom. Residential Manager will be responsible for purchasing bathroom supplies. |
705.6 (7) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(7) Maintain each bathroom in a functional, clean and sanitary manner at all times.
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Observations
Based on a physical plant inspection, the facility failed to maintain each bathroom in a functional, clean, and sanitary manner at all times.
The physical plant inspection was conducted between 12:45PM and 1:15PM and at the time of the inspection, the first-floor bathroom had an electric socket, located behind the sink faucet, that was missing caulk sealing around the outlet. Additionally, the second-floor bathroom had an electric socket, located behind the sink faucet, that was missing caulk sealing around the outlet and there was what appeared to be mold in the right lower corner of the shower stall.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Upon the conclusion of the exit interview, the maintenance person came to the program to seal the outlets with caulk. Program staff cleaned the identified shower stall for mold. Property department will assess for any additional treatments needed. During monthly property inspection, Program Director will assess for compliance with restroom regulations and arrange any needed repairs. |
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 date of the client's signature on release of information forms in one of seven client records reviewed.
Client #4 was admitted August 28, 2023 and was discharged March 13, 2024. There were release of information forms to an outside agency and to a drug screening laboratory, in the record, and both release forms did not include the date of when the client signed the form.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
During the June staff meeting, all staff will be trained on proper completion on the Consent to Release Information form. Clinical chart audits will be conducted monthly by the Program Director which will include review of all Consent to Release Information forms. |