INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 21, 2016 through January 22, 2016 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Livengrin Foundation, Inc. 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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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form completed between January 21, 2016 and January 22, 2016, the facility failed to ensure that all staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe in sixteen of thirty personnel records reviewed.
The findings include:
On January 21, 2016 and January 22, 2016, the SRFSR was reviewed, along with a review of the personnel files and sixteen out of thirty employees did not receive the HIV/AIDS training and/or the TB/STD training within the regulated timeframe for the employee's position, in specific employees #12, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, and 30.
Employee #12 was hired as a counselor on October 4, 2014. Employee #12 was due to complete the required HIV/AIDS training no later than October 4, 2015. There was no documentation in the employee file indicating that the employee received HIV/AIDS training as of the date of the inspection.
Employee #16 was hired as a FRAT unit employee on April 29, 2013. Employee #16 was due to complete the required HIV/AIDS training and the TB/STD training no later than April 29, 2015. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #17 was hired as a FRAT unit employee on May 1, 2013. Employee #17 was due to complete the required HIV/AIDS training and the TB/STD training no later than May 1, 2015. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #18 was hired as a staff technician on June 14, 2013. Employee #18 was due to complete the required HIV/AIDS training and the TB/STD training no later than June 14, 2015. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #19 was hired as a staff technician on March 27, 2012. Employee #19 was due to complete the required HIV/AIDS training and the TB/STD training no later than March 27, 2014. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #20 was hired as a staff technician on August 27, 2012. Employee #20 was due to complete the required TB/STD training no later than August 27, 2014. There was no documentation in the employee file indicating that the employee received TB/STD training as of the date of the inspection.
Employee #21 was hired as a staff technician on August 27, 2012. Employee #21 was due to complete the required TB/STD training no later than August 27, 2014. There was no documentation in the employee file indicating that the employee received TB/STD training as of the date of the inspection.
Employee #22 was hired as a staff technician on June 4, 2012. Employee #22 was due to complete the required TB/STD training no later than June 4, 2014. There was no documentation in the employee file indicating that the employee received TB/STD training as of the date of the inspection.
Employee #23 was hired as a staff technician on January 3, 2013. Employee #23 was due to complete the required TB/STD training no later than January 3, 2015. There was no documentation in the employee file indicating that the employee received TB/STD training as of the date of the inspection.
Employee #24 was hired as a marketing representative on February 28, 2013. Employee #24 was due to complete the required HIV/AIDS training and the TB/STD training no later than February 28, 2015. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #25 was hired as an intake unit employee on January 30, 2012. Employee #25 was due to complete the required TB/STD training no later than January 30, 2014. There was no documentation in the employee file indicating that the employee received TB/STD training as of the date of the inspection.
Employee #26 was hired as a maintenance worker/driver on November 15, 2013. Employee #26 was due to complete the required HIV/AIDS training and the TB/STD training no later than November 15, 2015. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #27 was hired as an assessor on November 8, 2012. Employee #27 was due to complete the required TB/STD training no later than November 8, 2014. There was no documentation in the employee file indicating that the employee received TB/STD training as of the date of the inspection.
Employee #28 was hired as an assessor on November 27, 2013. Employee #28 was due to complete the required HIV/AIDS training and the TB/STD training no later than November 27, 2015. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
Employee #29 was hired as the intake unit director on December 17, 2012. Employee #29 was due to complete the required HIV/AIDS training no later than December 17, 2014. There was no documentation in the employee file indicating that the employee received HIV/AIDS training as of the date of the inspection.
Employee #30 was hired as the FRAT unit director on January 6, 2014. Employee #30 was due to complete the required HIV/AIDS training and the TB/STD training no later than January 6, 2016. There was no documentation in the employee file indicating that the employee received the HIV/AIDS training and the TB/STD training as of the date of the inspection.
The findings were discussed with facility staff during the licensing process.
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Plan of Correction
Staff who are out of compliance with required training will be required to attend the next internal offering of TB/STD or HIV/AIDs, scheduled for April 2016. Patient education coordinator will be responsible for continued training compliance. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and employee records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of thirty employee records reviewed.
The findings included:
Thirty employee records and the SRFSR were reviewed on January 21, 2016 through January 22, 2016. Eleven of the employees reviewed were counselors. The facility failed to document at least 25 clock hours of annual training for the project's July 1, 2014 through June 30, 2015 training year in employee records #11 and 14.
Employee #11 was hired as a counselor on October 10, 2011 and was still in the position as of the date of the onsite inspection. The SRFSR, as well as employee #11's training file, only documented 23 hours of annual training for the training year reviewed.
Employee #14 was hired as a counselor on July 1, 2013 and was still in the position as of the date of the onsite inspection. The SRFSR, as well as employee #14's training file, only documented 23 hours of annual training for the training year reviewed.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Moving forward, clinician training hours will be reported by the Patient Education Coordinator on a quarterly basis to clinical managers. Training hours will directly factor into performance review outcomes. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based on a physical plant inspection, the facility failed to ensure that the hot water temperatures did not exceed 120 degrees fahrenheit in three of the four residential houses.
The findings included:
A physical plant inspection was conducted on January 22, 2016. The facility failed to ensure that the hot water temperatures did not exceed 120 degrees fahrenheit, specifically in the following residential houses: F House, G House, and the 500 Building.
The F House's water temperature reading was taken around 9:00 am and the temperature read 125 degrees fahrenheit.
The G House's water temperature reading was taken around 9:20 am and the temperature read 123 degrees fahrenheit.
The 500 Building's water temperature reading was taken around 9:40 am and the temperature read 145 degrees fahrenheit.
The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Heating elements were adjusted down to 115 degrees in E, F, G and 500 houses on 01/22/2016. The facilities department will conduct weekly checks to ensure temperatures remain at 120 degrees or below. The Director of Facilities is responsible for ongoing compliance. |
705.7 (b) (5) LICENSURE Food service.
705.7. Food service.
(b) A residential facility may operate a central food preparation area to provide food services to multiple facilities or locations. A residential facility that operates an onsite food preparation area or a central food preparation area shall:
(5) Keep cold food at or below 40F, hot food at or above 140F, and frozen food at or below 0F.
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Observations
Based on an inspection of the physical plant, the facility failed to ensure that freezer temperatures were at or below 0 degrees Fahrenheit. Additionally, the facility failed to provide documentation of frozen food being stored at or below 0 degrees Fahrenheit and cold food at or below 40 degrees Fahrenheit.
The findings include:
The physical plant inspection was conducted on January 22, 2016 from 8:45 am to 10:00 am. Refrigerators/Freezers are provided for client food storage in the residential houses: E House, F House, G House, in addition to the refrigerator/freezer located in the main kitchen of the facility.
The facility's main kitchen freezer temperature read 5 degrees Fahrenheit at the time of the inspection. Additionally, after reviewing the temperature logs for the period of February 2015 through January 2016, the main kitchen freezer was above 0 degrees Fahrenheit 19 days in February 2015, 30 days in March 2015, 29 days in April 2015, 28 days in May 2015, 29 days in June 2015, 30 days in July 2015, 14 days in August 2015, 19 days in September 2015, 24 days in October 2015, 10 days in November 2015, and 9 days in December 2015.
The facility's residential "E House" has one refrigerator/freezer. The facility documented temperatures for 22 days in January 2016 and all 22 days the freezer temperatures were above 0 degrees Fahrenheit. There were no other temperature logs provided; therefore, there is no way to determine if the frozen food was stored at 0 degrees Fahrenheit, as well as cold food at or below 40 degrees Fahrenheit since the prior licensing inspection in February 2015.
The facility's residential "F House" has one refrigerator/freezer. The facility documented temperatures for 22 days in January 2016 and for 17 days the freezer temperatures were above 0 degrees Fahrenheit. There were no other temperature logs provided; therefore, there is no way to determine if the frozen food was stored at 0 degrees Fahrenheit, as well as cold food at or below 40 degrees Fahrenheit since the prior licensing inspection in February 2015.
The facility's residential "G House" has one refrigerator/freezer. The facility documented temperatures for 22 days in January 2016 and all 22 days the freezer temperatures were above 0 degrees Fahrenheit. There were no other temperature logs provided; therefore, there is no way to determine if the frozen food was stored at 0 degrees Fahrenheit, as well as cold food at or below 40 degrees Fahrenheit since the prior licensing inspection in February 2015.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The freezers in the kitchen, E, F and G house were turned up on 01/22/2016 to 0 degrees. Daily log will be completed and any temperatures above 0 degrees will be reported to the Director of Facilities for repair. Director of Nutritional Services will be responsible for ongoing compliance. |