INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 30, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, STR Addiction Counseling, LLC 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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705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the Facility failed to instruct staff in the use of the fire extinguisher upon staff employment or prior to the facility opening in six of six personnel record reviewed.
The findings include:
Six personnel record were reviewed which required documentation of fire extinguisher training prior to July 30, 2014. The facility failed to ensure that employees # 1, 2, 3, 4, 5, and 6 completed fire extinguisher training upon employment or prior to the facility opening.
Employee # 1 was hired as the project director on January 7, 2013, prior to the facility opening on December 24, 2013. The employee did not complete fire extinguisher training until July 15, 2014.
Employee # 2 was hired as the clinical supervisor on January 13, 2014. The employee did not complete fire extinguisher training until July 15, 2014.
Employee # 3 was hired as a counselor on May 7, 2014. The personal record of employee # 3 did not documentation fire extinguisher training as of July 30, 2014.
Employee # 4 was initially hired on April 14, 2014 and hired as a counselor on June 24, 2014. The employee did not complete fire extinguisher training until July 15, 2014.
Employee # 5 was hired as a counselor on March 17, 2014. The employee did not complete fire extinguisher training until July 15, 2014.
Employee # 6 was hired as a counselor on April 28, 2014. The employee did not complete fire extinguisher training until July 15, 2014.
The findings were confirmed by the project director on July 30, 2014.
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Plan of Correction
The Clinical Director will be responsible to receive a "train the trainer" training by the Local Township Fire Marshall in the use of a fire extinguisher no later than September 30th 2014. The Clinical Director will keep an up to date certification in fire extinguisher training and develop a training that will be used for each new employee hired at the facility. The fire extinguisher training will be developed no later than October 15th of 2014. The Facility Director will ensure that the training occurs and is developed by the aforementioned time frames. Moving forward, fire extinguisher training will be provided during the training period of each employee, prior to the start of their regular position. The Clinical Director will ensure that Employee #3 will have Fire Extinguisher training completed by 10/15/2014. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill records, the facility failed to conduct fire drills at least once a month in one of seven months reviewed. Also, the facility failed to ensure all personnel on all shifts were trained to perform assigned tasks during emergencies in six of six personnel records reviewed. In addition, the facility failed to maintain a written fire drill record including the amount of time it took for evacuation and/or the number of persons in the facility at the time of the drill in six of seven months reviewed.
The findings include:
Fire drill records were reviewed prior to July 30, 2014. The records were reviewed from the period covering January 2014 to July 2014. The facility did not document a fire drill in the month of January 2014. Also, the facility did not maintain a written fire drill record including the amount of time it took for evacuation and/or the number of persons in the facility at the time of the drill from February 2014 to July 2014.
Six personnel record requiring documentation that personnel had been trained to perform assigned tasks during emergencies were reviewed prior to July 30, 2014. The facility failed to ensure that employees # 1, 2, 3, 4, 5, and 6 had completed emergency training prior to working their first shift or the facility opening.
Employee # 1 was hired as the project director on January 7, 2013, prior to the facility opening on December 24, 2013. The employee did not complete emergency training until July 15, 2014.
Employee # 2 was hired as the clinical supervisor on January 13, 2014. The employee did not complete emergency training until July 15, 2014.
Employee # 3 was hired as a counselor on May 7, 2014. The employee # 3's personal record did not have documentation of emergency training as of July 30, 2014.
Employee # 4 was initially hired on April 14, 2014 and hired as a counselor on June 24, 2014. The employee did not complete emergency training until July 15, 2014.
Employee # 5 was hired as a counselor on March 17, 2014. The employee did not complete emergency training until July 15, 2014.
Employee # 6 was hired as a counselor on April 28, 2014. The employee did not complete emergency training until July 15, 2014.
The findings were confirmed during an interview with the project director on July 30, 2014.
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Plan of Correction
Moving forward the Clinical Director will ensure that a fire drill is completed for the current month by the 21st. If a fire drill has not been completed, the Clinical Director will conduct one. The Facility Director will ensure that the Fire Drill was completed by the 28th of the current month. If not, the Facility Director will direct the Clinical Director to complete the Fire Drill that day or the following business day. The Clinical Director will be responsible to make sure that fire drills are conducted at least once a month.
On 8/5/14 the Clinical Director updated the facility fire drill form to include the time it takes for everyone to evacuate the building during a fire drill and the amount of persons in the facility at the time of the drill. During the fire drill the Clinical Director will observe and document the amount of time it takes everyone to evacuate and the number of persons in the facility at the time the fire drill is conducted. The Facility Director reviewed the updated fire drill form and approved its use on 8/5/14.
Moving forward the Clinical Director will ensure that each new employee hired will be trained in emergency procedures during their initial training period, prior to the start of the start of their position. Emergency protocols and a training for those protocols is already in place, but will now be trained to new employees prior to the start of their first working day. The Facility Director will complete regular personnel files (once a quarter) to ensure each employee is trained properly and according to the time frame designated above.
The Clinical Director will ensure that Employee #3 will receive their emergency training by 10/15/2014. |
709.83(a)(8) LICENSURE Client records
709.83. 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:
(8) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete client record that included a record of services in four of ten client records reviewed.
The findings include:
Ten client records requiring documentation of a complete client record were reviewed on July 30, 2014. The facility failed to document a record of services in client records # 3, 5, 6, and 7.
Client # 3 was admitted May 6, 2014 and was still an active client as of July 30, 2014. The record of service was missing from 5/6/14 until the client was step down to out-patient on 6/2/14.
Client # 5 was admitted May 19, 2014 and was discharged on July 16, 2014. The record of service was missing from May 19, 2014 until the client was step down to out-patient on June 3, 2014.
Client # 6 was admitted May 13, 2014 and was discharged on June 18, 2014. The record of service was missing from May 13, 2014 until the client was step down to out-patient on May 30, 2014.
Client # 7 was admitted April 26, 2014 and was discharged on June 9, 2014. The record of service was missing from April 26, 2014 to June 9, 2014.
The findings were confirmed during an interview with project director on July 30, 2014.
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Plan of Correction
Effective 9/1/14, for three months, the Clinical Director will complete routine checks, at least one audit weekly to ensure that a record of service is being completed for each client in services. The facility will use its current record of service forms. After the three month period, the Clinical Director will do one audit a month on three client records to ensure the record of service is being used regularly and accurately. The Clinical Director is responsible to make sure that the record of service is completed for each client record. The Clinical Director is also responsible to ensure that any missing records of service are completed accurately and thoroughly. This must be completed by 10/15/2014.
The Clinical Director will make sure that the record of services are completed for client #3 by 10/15/2014. |
709.93(a)(3) 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:
(3) Record of services provided.
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Observations
Based on a review of client records, the facility failed to document a complete client record that included a record of services in six of nine client records reviewed.
The findings include:
Nine client records requiring documentation of a complete client record were reviewed on July 30, 2014. The facility failed to document a record of services in client records # 1, 2, 3, 4, 5, and 6.
Client # 1 was admitted May 27, 2014 and was still an active client as of July 30 2014. The record of service was missing from June 2014 to July 2014.
Client # 2 was admitted April 22, 2014 and was still an active client as of July 30, 2014. The record of service was missing from June 2014 to July 2014.
Client # 3 was admitted May 6, 2014 and was still an active client as of July 30, 2014. The record of service was missing from June 2014 to July 2014.
Client # 4 was admitted March 31, 2014 and was still an active client as of July 30, 2014. The record of service was missing from May 2014 to July 2014.
Client # 5 was admitted May 19, 2014 and discharged July 16, 2014. The record of service was missing from June 2014 to July 2014.
Client # 6 was admitted May 13, 2014 and discharged June 18, 2014. The record of service was missing from May 2014 to June 2014.
The findings were confirmed during an interview with project director on July 30, 2014.
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Plan of Correction
Effective 9/1/14, for three months, the Clinical Director will complete routine checks, at least one audit weekly to ensure that a record of service is being completed for each client in services. The facility will use its current record of service forms. After the three month period, the Clinical Director will do one audit a month on three client records to ensure the record of service is being used regularly and accurately. The Clinical Director is responsible to make sure that the record of service is completed for each client record. The Clinical Director is also responsible to ensure that any missing records of service are completed accurately and thoroughly. This must be completed by 10/15/2014.
The Clinical Director will make sure that the record of services for clients # 1, 2, 3, 4 are completd by 10/15/2014. |