INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 19, 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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704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of four personnel records, the facility failed to ensure there was a mechanism to collect feedback on completed trainings in one record reviewed.
Employee #2 was hired as the Facility Director on May 17, 2021 and was still current in that position at the time of the inspection. Employee #2 did not have a mechanism to collect feedback on completed trainings documented in the personnel record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Program Director will begin utilizing the training evaluation forms issued by RHD.
- Every staff will complete a training evaluation concluding all trainings done as an employee at RHD.
- These evaluations will be housed in the staff training file.
- Resource Coordinator will keep records of all trainings and evaluations.
- Resource Coordinator will address missing documents at monthly staff meetings. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection conducted on July 19, 2022, the facility failed to ensure the hot water temperature did not exceed 120 degrees Fahrenheit.
The hot water temperature read 130 degrees Fahrenheit in all of the facility ' s bathrooms at the time of the inspection.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
- Program Director reported these findings to building landlord.
- Program Director will follow up with landlord monthly.
- If there is no resolution, corporate entities will intervene with landlord.
- Facility will monitor water temperature daily and utilize a log book that will be housed in the Life Skills office.
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705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
Based on a physical plant inspection on July 19, 2022, the facility failed to maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
The facility did not have a fire extinguisher in the kitchen area.
These findings were discussed with facility staff during the licensing process.
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Plan of Correction
- An ABC extinguisher was installed the day after the review.
- Pictures were sent to licensing agent via email.
- This newly installed fire extinguisher will become part of the quarterly fire safety inspections done by the landlord.
- RHD will also monitor dates on the fire extinguishers to be sure they are charged and current.
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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 seven client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for clients in one of one applicable record reviewed.
Client #5 was admitted on March 31, 2022 and discharged Against Medical Advice (AMA) on June 9, 2022. The facility failed to follow their policy related to AMA discharges of calling the Emergency Contact within twelve hours.
These findings were reviewed with the project staff during the licensing process.
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Plan of Correction
- Staff will call emergency contacts within 12 hours of discharge.
- Staff will complete an incident report reflecting this.
- Staff will document this phone call in the electronic medical record.
- RHD CORE (Program Director and Assistant Program Director) will facilitate a training with all staff on incident reporting and follow up actions that need to be taken, which includes notifying emergency contacts. This training will happen in the month of September.
- Staff will sign and attestation reflecting that they understand AMA procedures and notifications.
- Program Director and Office Manager will put attestations in each staff personnel file.
- On Call staff will be responsible for ensuring that staff on duty make the appropriate follow up phone calls, as well as ensuring appropriate documentation is completed. |
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 seven client records, the facility failed to have written documentation that included the project may not discriminate in the provision of services on the basis of marital status, in all records reviewed.
The findings were discussed with project staff during the licensing process.
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Plan of Correction
- Clients rights documents have been revised to include marital status.
- Copies of this document can be reviewed by DDAP.
- This document has been changed in its entirety. The former, incorrect document no longer exists.
- Moving forward, Therapists and Resource Coordinator will ensure that they are implementing the correct document into the record. They will verify that marital status is evident on the current document.
- Prior to signing off on intake documentation, Assistant Program Director will ensure that the appropriate/current documents were utilized.
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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 seven client records, the facility failed to ensure that treatment and rehabilitation plans were reviewed and updated at least every 30 days in five out of seven applicable records reviewed.
Client #1 was admitted on March 9, 2022 and was active at the time of the inspection. A comprehensive treatment plan was completed on March 11, 2022 and a treatment plan update was due by April 11, 2022; however, the next update was not completed until April 22, 2022. Another treatment plan update was completed on June 9, 2022 with the next update due by July 9, 2022; however, the next update was not completed until July 11, 2022.
Client #2 was admitted on March 10, 2022 and was active at the time of the inspection. A treatment plan update was completed on June 10, 2022 with the next update due by July 10, 2022; however, the next update was not completed until July 16, 2022.
Client #3 was admitted on March 21, 2022 and was active at the time of the inspection. A treatment plan update was completed on May 21, 2022 with the next update due by June 21, 2022; however, the next update was not completed until July 16, 2022.
Client #5 was admitted on May 10, 2022 and was discharged on June 9, 2022. A comprehensive treatment plan was completed on April 2, 2022 and a treatment plan update was due by May 2, 2022; however, the next update was not completed until May 19, 2022.
Client #7 was admitted on October 28, 2021 and was discharged on March 21, 2022. A treatment plan update was completed on December 7, 2021 and a treatment plan update was due by January 7, 2022; however, the next update was not completed until January 12, 2022. The next treatment plan update was due by February 12, 2022; however, was not completed until February 14, 2022. The following treatment plan update was due by March 14, 2022 but there was not one documented in the record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Assistant Director will run the treatment plan report daily before morning meeting.
- During morning meeting, Assistant Director will update clinicians of due dates and deadlines.
- Should there be a valid reason a treatment plan is late, proper documentation reflecting this will be entered into the electronic medical record.
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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 seven client records, the facility failed to provide a complete client record on an individual which includes information relative to the client's involvement with the project to include follow-up information in three out of three applicable records reviewed.
Client # 5 was admitted on March 31, 2022 and was discharged on June 9, 2022. There was no follow-up information documented in the client record.
Client # 6 was admitted on March 22, 2022 and was discharged on April 6, 2022. There was no follow-up information documented in the client record.
Client # 7 was admitted on October 28, 2021 and was discharged on March 21, 2022. There was no follow-up information documented in the client record.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
- Resource Coordinator will enter clients follow up information in the discharge note in the electronic medical record.
- Resource Coordinator will also continue to maintain the discharge follow up spreadsheet that has been utilized since inception of RHD CORE. During this audit, this spreadsheet was not available due to a staff emergency.
- Assistant Program Director will review follow up information prior to signing off on discharge summaries.
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709.53(a)(12) LICENSURE Work as treatment
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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Based on a review of seven client records, the facility failed to verify that work done by the clients at the project is an integral part of their treatment and rehabilitation plan in all seven client records reviewed.
These findings were discussed with facility staff during the inspection process.
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Plan of Correction
- In house work/chores will be added to the clients treatment plan. Assistant Program Director will monitor.
- Therapist will work in conjunction with the client to determine where the client feels they can benefit from work therapy.
- The client will identify goals for his treatment plan in this domain.
- Assistant Program Director will ensure that the goals are person-centered for individualized treatment prior to signing off on treatment plans in the electronic medical record.
- Chore discussion has been added to morning meeting and will be documented in the electronic medical record. These notes will be monitored by Life Skills Supervisors.
- "Big Clean" group is a group where direct care staff assist clients in maintaining their living space. Life Skills supervisors will ensure that this group is properly documented. Documentation will be monitored by Life Skills supervisors.
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