INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on June 25, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, TrueNorth Wellness Services 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:
|
Plan of Correction
|
704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
|
Observations
Based on a review of personnel training records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that the project director receive at least 12 clock hours of training annually.
The findings include:
According to the Staffing Requirements Facility Summary Report, the facility training year runs from October 1 through September 30.
The project director's record was reviewed specifically for training hours for the 2012-2013 training year on June 23, 2014. There was no documentation of any clock hours obtained for the 2012-2013 training year in personnel record #1.
Employee # 1 was hired as the project director on November 1, 2007. Employee # 1 did not have any documented clock hours of training from October 1, 2012 through September 3, 2013.
The findings were confirmed with the Drug and Alcohol coordinator.
|
Plan of Correction
Our training year runs from October 1 through September 30. Employee #1 will be leaving the agency tentatively between 1 August 2014 and 1 October 2014. Once her replacement has been named, the new hire procedures will be completed within 7 days of hire to include the requirement of 12 documented training hours per training year. This standard will be reviewed monthly with the new employee to ensure compliance. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
|
Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies.
The findings include:
Two personnel records were reviewed on June 23, 2014 to verify that all personnel on all shifts had been trained to perform assigned tasks during emergencies. The facility failed to document the completion of emergency training in one of two personnel records reviewed, specifically employee #4.
Employee # 4 was hired by the project as an intern on July 30, 2013 and became a drug and alcohol counselor on June 16, 2014. As of the date of inspection, there was no documentation to verify that employee #4 received emergency training.
The findings were confirmed during a conversation with clinical director.
|
Plan of Correction
The Clinical Supervisor met with Employee #4 on July 9, 2014. At that time the disaster plan was signed and reviewed.
During that meeting with employee #4, the Chain of Responsibility was reviewed, she was introduced to the different routes of evacuation, she was introduced to the Building Supervisor, other program managers and the front office staff, and we walked the building pointing out fire extinguishers.
In the future,if any new therapists are hired, this standard will be completed within 7 days of hire. |
709.93(a) LICENSURE Client records
709.93. 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:
|
Observations
Based on the review of client records, the facility failed to document a complete client record to include case consultations and/or follow ups in three out of seven client records.
The findings include:
Eight client records were reviewed on June 24, 2014. Seven of those records were required to include documentation of a case consultation. The facility failed to document a case consultation where required in two out of seven records, specifically # ' s 1 and 3. Additionally out of the four discharged records reviewed, one was required to document a follow-up; however it was not in the client record.
Client # 1 was admitted on March 5, 2014, a case consult was due by June 5, 2014. As of the date of inspection there was no documentation of a case consultation for client #1.
Client # 3 was admitted on December 19, 2014, a case consultation was due by March 19, 2014. As of the date of inspection, there was no documentation of a case consult for client #3.
Client # 5 was discharged on May 16, 2014. As of the date of inspection, there was no documentation of follow-up conducted for client #5.
The findings were reviewed with the clinical director.
|
Plan of Correction
The Clinical Director will meet with the York clinicians on August 5, 2014. A review of this standard will be completed at that time. Records will be reviewed weekly until 1 October 2014. After that date the review will take place monthly. Any issues will be brought to the clinician of record to update the record as indicated.
The Clinical Supervisor reviewed the list of cases inspected, record #5 was discharged 5/16/14, a follow up letter is documented in the chart as being sent on 7/18/14. |