INITIAL COMMENTS
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This report is a result of an onsite, provisional license, follow-up inspection conducted on November 20, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the onsite follow-up 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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705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
The facility failed to include all required information on the fire drill record. Fire drills documented for October 2019 and November 2019 were reviewed on November 20, 2019.
A fire drill documented for October 23, 2019 was missing the time of the drill, and if the smoke detector or fire alarm was operable.
Fire drills documented on November 8, 2019 at 6:25am, November 8, 2019 at 9:38pm, and November 13, 2019 at 5:45am do not document problems encountered.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
RHD CORE has implemented a weekly property inspection process effective 11/20/19 where the Assistant Director and Direct Care Supervisor conduct an inspection of the physical plant. Part of this inspection includes a review of the Fire Drill log and documentation of the inspection. The Assistant Director is responsible for ensuring that the Fire Drill log is complete and accurate during these weekly inspections. |
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
The facility failed to obtain an informed and voluntary consent for a pharmacy in two of three client records reviewed on November 20, 2019.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
Effective 11/20/19, the Nursing Department will complete a release of information form for the specialty pharmacy used to provide Sublocade. The completion of this consent form has also been added to a Medical Checklist that is signed off on by the Nursing Department prior to the client beginning Suboxone or Sublocade. We have added the Assistant Director's signature to this checklist to ensure that the checklist is complete and accurate and as a double check to ensure that a release of information form for the specialty pharmacy is completed. |
709.34 (c) (4) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(4) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
The facility failed to notify the Department within three business days of an event requiring the presence of ambulance personnel.
A review of incident reports from July 2017 to September 2019 was conducted.
Nineteen unusual incident reports documented that an ambulance was called to the facility, but the incidents were not reported to the Department.
The findings were reviewed with the facility staff during the inspection.
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Plan of Correction
As of 9/24/19, the Director confirmed that the Assistant Director had the current DDAPL email address for where incident reports are to be sent. The Assistant Director is responsible for ensuring that incident reports are sent to this email address within 24 hours of the incident's occurrence. Between the date of 9/24/19 and this audit, no Unusual Incidents had occurred so the POC is being maintained. |