INITIAL COMMENTS
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This report is a result of an on-site follow-up inspection conducted on January 11, 2024 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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705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of the staffing records, the facility failed to ensure that all personnel were instructed in the use of fire extinguishers upon employment in one of two records reviewed.
Staff #1 was hired as a counselor on March 20, 2023 and still a current employee. According to the POC approved by the Department, fire extinguisher training for Staff #1 was due to be completed by August 31, 2023 but was not completed until December 13, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 28, 2023 licensing renewal inspection.
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Plan of Correction
Use of fire extinguishers has been added to the fire safety training provided in onboarding for staff hired after February 12, 2024. Clinical Manager and Program Director for clinical staff and Office Manager and Program Director for non-clinical staff will complete the on boarding with new hires and submit signed documentation to Program Director for review.
Completion of fire safety training for new hires has been added to the weekly plan of correction tracking form that is completed by Clinical Manager and Program Director, and submitted to Regional Director for review.
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705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the staffing records, the facility failed to ensure that all personnel were trained to perform assigned tasks during emergencies in one of two records reviewed.
Staff #1 was hired as a counselor on March 20, 2023 and still a current employee. According to the POC approved by the Department, verification that staff were trained to perform assigned tasks during emergencies for Staff #1 was due to be completed by August 31, 2023 but was not completed until December 13, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 28, 2023 licensing renewal inspection.
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Plan of Correction
Assigned tasks for staff in the event of an emergency has been added the onboarding schedule for new hires to be completed within the first 7 days of employment for all staff hired after February 12, 2024. Clinical Manager and Program Director for clinical staff and Office Manager and Program Director for non-clinical staff will complete the on boarding with new hires and submit signed documentation to Program Director for review.
Completion of fire safety training for new hires has been added to the weekly plan of correction tracking form that is completed by Clinical Manager and Program Director, and submitted to Regional Director for review.
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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
Based on a review of fire drill records, the facility failed to maintain a fire drill record which included all of the required components.
The fire drills were reviewed for the period of October 2023 to December 2023. October 2023 fire drill log was missing problems encountered. November 2023 was missing exit route used and problems encountered. December 2023 was missing exit route used and problems encountered.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 28, 2023 licensing renewal inspection.
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Plan of Correction
Effective immediately, the fire drill form has been updated to include the amount of time it took for evacuation, 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. Staff are to complete the form immediately and place completed form in Program Director's mailbox. Program Director will review and sign the completed form to ensure it is completed properly and file. Appropriate completion of the fire drill record has been added to weekly plan of correction tracking form that is completed by Clinical Manager and Program Director, and submitted to Regional Director for review. All staff were provided training on the updated form on January 17, 2024. |
705.10 (d) (8) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(8) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based on a review of fire drill records, the facility failed to set off a fire alarm or smoke detector during each fire drill.
The fire drills were reviewed for the period of October 2023 to December 2023. November 2023 did not indicate whether a fire alarm or smoke detector was set off during the drill.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, if the completed fire drill form indicates the smoke detector was not set off, Program Director will discuss the concern with building management to have the alarms checked and conduct a separate fire drill to ensure the fire alarm is set off for monthly fire drills.
Program Director met with building manager on 2/23/24 to discuss the procedure for setting off fire alarms. He reported that alarms are activated during all fire drills and regularly maintained to ensure they are operational in the event of an emergency. |
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 have written documentation that included the project may not discriminate in the provision of services on the basis of ethnicity, in all records reviewed.
The findings were discussed with project staff during the licensing process.
This is a repeat citation from the July 19, 2022 and June 28, 2023 annual licensing inspections.
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Plan of Correction
Effective immediately, the master client rights form has been updated to include that the project may not discriminate in the provision of services based on ethnicity. Clinical Manager will review the client rights form within 7 days of admission to ensure the accurate client rights document is completed and report completion on the weekly plan of correction tracking form that is completed by Clinical Manager and Program Director, and submitted to Regional Director for review. |
709.32 (c) (4) (i) - (ii) LICENSURE Medication control
§ 709.32. Medication control.
(4) Methods for control and accountability of drugs, including, but not limited to:
(i) Who is authorized to remove drug.
(ii) The program ' s system for recording drugs, which includes the name of the drug, the dosage, the staff person, the time and the date.
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Observations
Based on a review of client records, the facility failed to provide client medications, as prescribed, in four of seven client records.
Medication Administration Records (MAR) had gaps which were missing information whether clients were administered medications certain days or if medications were missed and what the cause was. The following clients had the following dates in their MARs with no explanation of whether medication was missed or administered.
Client #3 was admitted on October 4, 2023 and discharged on December 5, 2023.
Medication #1 was prescribed for one tablet by mouth every day in the evening. Medication #1 was not administered as prescribed on October 21, 2023.
Medication #2 was prescribed for one capsule by mouth every evening. Medication #2 was not administered as prescribed on October 21, 2023.
Client #4 was admitted on October 18, 2023 and discharged on December 17, 2023.
Medication #1 was prescribed for one capsule by mouth at bedtime. Medication #1 was not administered as prescribed on October 21, November 17, and December 4, 2023.
Client #5 was admitted on September 13, 2023 and discharged on November 2, 2023.
Medication #1 was prescribed for one tablet per mouth three times per day. Medication #1 was not administered as prescribed during the 9 pm time frames on October 21, 22, and 27, 2023.
Medication #2 was prescribed for one tablet per mouth once per day. Medication #2 was not administered as prescribed on October 12, 2023.
Medication #3 was prescribed for two tablet per mouth once per day. Medication #3 was not administered as prescribed on October 21, 22, and 27, 2023.
Client #7 was admitted on September 27, 2023 and discharged on December 30, 2023.
Medication #1 was prescribed for 1 tablet by mouth two times per day. Medication #1 was not administered as prescribed on October 26, 2023 at 9 pm.
Medication #2 was prescribed for 1 tablet by mouth every day in the evening. Medication #2 was not administered as prescribed on October 26, 2023.
Medication #3 was prescribed for one tablet by mouth every day at noon. Medication #3 was not administered as prescribed on November 19 and 26, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the June 28, 2023 licensing renewal inspection.
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Plan of Correction
A new procedure has been implemented effective immediately in which during shift change the medication officer for both shifts will review the MAR together to ensure all documentation has been completed appropriately before the close of each shift. LPN is reviewing the Medication Administration Records (MAR) weekly to review that documentation is completed accurately. Gaps identified on the MAR are reported weekly on the plan of correction tracking form that is completed by Clinical Manager and Program Director, and submitted to Regional Director for review.
Program Director reviewed medication administration and documentation with all staff on January 17, 2024. Office Manager and LPN will complete supervision with medication officers on medication administration and documentation to ensure staff are properly trained in procedures and understand the importance of medication administration by March 31, 2024.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department.
Plans of correction for client rights were submitted and approved by the Department for the July 19, 2022 and June 28, 2023 annual licensing inspections.
Client rights were again found to be a deficiency in the January 2024 follow up licensing inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Effective immediately, Clinical Manager and Program Director will complete a weekly plan of correction tracking form that is submitted to Regional Director and reviewed in weekly supervision. All areas of the plan of correction will be reflected on the tracking form and progress will be reviewed. |