INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 25-26, 2015 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 in four of six personnel records reviewed.
The findings include:
Four personnel records, which required documentation of fire extinguisher training, were reviewed on August 25, 2015. The facility failed to ensure that employees, #3, 4, 5 and 6 completed fire extinguisher training upon employment.
Employee #3 was hired as a counselor on December 14, 2015. Employee #3 did not complete fire extinguisher training until May 20, 2015.
Employee #4 was hired as a counselor on February 16, 2015. Employee #4 had not completed fire extinguisher training at the time of the inspection.
Employee #5 was hired as a Behavior Technician on April 1, 2015. Employee #5 did not complete fire extinguisher training until May 20, 2015.
Employee #6 was hired as a Behavior Technician on May 12, 2015. Employee #6 had not completed fire extinguisher training by the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the July 30, 2014 inspection.
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Plan of Correction
The Clinical Director has created a power point training that teaches the proper use of fire extinguishers and emergency procedures. Effective 11/1/2015, each new employee hired will receive the fire extinguisher and emergency procedures training by the Program Manager on the 3rd day of their employment, during their orientation. The Program Manager will present the power point and have the employee sign a sign-in sheet to indicate their presence in the training. The sign-in sheet will be submitted to the administrative assistant the day it is completed. The Administrative Assistant will print and file a fire extinguisher and emergency procedures training certificate and place it in the employee's personnel file on the following business day. The Personnel files for all new employees will be audited once a month by the Director of Operations in order to ensure the presence of the training certificate. Employees 3,4, and 6 will receive fire extinguisher training by 11/1/2015. |
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 personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
Four personnel records, which required documentation of emergency training, were reviewed on August 25, 2015. The facility failed to ensure that employees, #3, 4, 5 and 6 completed emergency training upon employment.
Employee #3 was hired as a counselor on December 14, 2015. Employee #3 did not complete emergency training until May 20, 2015.
Employee #4 was hired as a counselor on February 16, 2015. Employee #4 had not completed emergency training at the time of the inspection.
Employee #5 was hired as a Behavior Technician on April 1, 2015. Employee #5 did not complete emergency training until May 20, 2015.
Employee #6 was hired as a Behavior Technician on May 12, 2015. Employee #6 had not completed emergency training by the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation. The facility was previously cited for non-compliance with this standard during the July 30, 2014 inspection.
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Plan of Correction
The Clinical Director has created a power point training that teaches the proper use of fire extinguishers and emergency procedures. Effective 11/1/2015, each new employee hired will receive the fire extinguisher and emergency procedures training by the Program Manager on the 3rd day of their employment, during their orientation. The Program Manager will present the power point and have the employee sign a sign-in sheet to indicate their presence in the training. The sign-in sheet will be submitted to the administrative assistant the day it is completed. The Administrative Assistant will print and file a fire extinguisher and emergency procedures training certificate and place it in the employee's personnel file on the following business day. The Personnel files for all new employees will be audited once a month by the Director of Operations in order to ensure the presence of the training certificate. Employees 3,4, and 6 will receive fire extinguisher training by 11/1/2015. |
709.82(a) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client in three of four client records.
The findings include:
Four partial hospitalization client records, which required documentation of an individualized treatment and rehabilitation plan, were reviewed on August 25, 2015. The facility failed to show that the individualized treatment and rehabilitation plan was developed with the client either by signature from the client and counselor or documentation in the client's progress notes documenting that the treatment plan was developed with the client in client records, #1, 3 and 4.
Client #1 was admitted on July 27, 2015 and a preliminary treatment and rehabilitation plan was developed and signed by the client on that date. The individualized treatment and rehabilitation plan was developed on July 31, 2015. This treatment plan was signed by the client on August 21, 2015.
Client #3 was admitted on August 6, 2015 and a preliminary treatment and rehabilitation plan was developed and signed by the client on that date. The individualized treatment and rehabilitation plan was developed on August 14, 2015. This treatment plan was signed by the client on August 24, 2015.
Client #4 was admitted on June 25, 2015 and a preliminary treatment and rehabilitation plan was developed and signed by the client on that date. The individualized treatment and rehabilitation plan was developed on June 29, 2015. This treatment plan was signed by the client on July 8, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will meet with all of the Clinicians at the program and communicate/retrain on the existing policy of having treatment plans developed with the client (while they are present) and having the client sign the treatment plan on the day it was developed in order to indicate their presence. The communication/retraining will occur no later than 11/1/2015. Effective 11/1/2015, the Clinical Director will complete client record reviews within 5 business days of a client admitting into treatment, in particular treatment plans are completed accurately and signed off on appropriately by the client. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that was developed with the client in four of six client records.
The findings include:
Six outpatient hospitalization client records were reviewed on August 26, 2015. Four of the client records required documentation of an individualized treatment and rehabilitation plan which was developed with the client. Client records # 6, 7, 8 and 9 did not contain an individualized treatment and rehabilitation plan that was developed with the client.
Client #6 was admitted on June 25, 2015 and a preliminary treatment and rehabilitation plan was developed and signed by the client on that date. The individualized treatment and rehabilitation plan was developed on July 2, 2015. This treatment plan was signed by the client on August 23, 2015.
Client #7 was admitted on July 23, 2015 and a preliminary treatment and rehabilitation plan was developed and signed by the client on that date. The individualized treatment and rehabilitation plan was developed on July 30, 2015. This treatment plan was signed by the client on August 21, 2015.
Client #8 was admitted on July 31, 2015 and a preliminary treatment and rehabilitation plan was developed and signed by the client on that date. The individualized treatment and rehabilitation plan was developed on August 7, 2015. This treatment plan was signed by the client on August 21, 2015.
Client #9 was admitted on June 8, 2015 and a preliminary treatment and rehabilitation plan was developed and signed by the client on that date. The individualized treatment and rehabilitation plan was developed on June 12, 2015. This treatment plan was signed by the client on July 7, 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Director will meet with all of the Clinicians at the program and communicate/retrain on the existing policy of having treatment plans developed with the client (while they are present) and having the client sign the treatment plan on the day it was developed in order to indicate their presence. The communication/retraining will occur no later than 11/1/2015. Effective 11/1/2015, the Clinical Director will complete client record reviews within 5 business days of a client admitting into treatment, in particular treatment plans are completed accurately and signed off on appropriately by the client. |