INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on September 17, 2007 through September 18, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, My Sister's Place Thomas Jefferson University 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 and a plan of correction is due on October 18, 2007.
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Plan of Correction
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704.11(a) LICENSURE Staff Development Procedure
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
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Observations
Based on a review of the staff development policy and training documentation, the facility failed to document staff development policies and procedures that coincide with the facility's actual practice.
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Plan of Correction
704.11(a)
POC: The policy and procedure has been rewritten with more explicit details regarding each step and the purpose of each form used to develop the staff training for the upcoming year. These steps include the time of the year, who is responsible, how the information is used to formulate the upcoming training needs, who approves it, how staff are notified, and the required feedback. Also, the Individual Training Sheet no includes an additional column with the particular resource listed for the employee and supervisor.
Eash supervisor has been given the new policy and a review will be given so that each supervisor is aware of the
the more detailed process.
Person(s) responsible:
Program Director
Supervisors
Timeframe for completion:
10/16/07
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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 and training records, the facility failed to document six hours of HIV/AIDS training for employee #6.
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Plan of Correction
704.11(c)(1) Mandatory Communicable Disease POC: Employee #6 is scheduled to attend HIV Training on 10/16/07 Training. Employee #6 was previously scheduled to attend HIV training in November 2007, but cancelled due to illness.
Person(s) responsible:
Supervisors
Administrative Assistant
Timeframe for completion: 10/16/07 |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of training records and staff schedules, the facility failed to provide first aid coverage on the overnight shift for September 1 and 2, 2007.
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Plan of Correction
704.11(c)(2) CPR Certification POC: First Aid training has been scheduled for 10/1/07 to insure all overnight staff have met compliance requirements.
Person(s) responsible:
Program Director
Supervisors
Administrative Assistant
Timeframe for completion:
10/1/07
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705.2 (3) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(3) Keep exterior exits, stairs and walkways lighted at night.
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Observations
Based on a physical plant inspection, the facility failed to provide external lighting for the fourth, third, and second floors between the main building and the fire towers.
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Plan of Correction
10/705.2 (3) Building exterior and grounds
POC: The lights between the floor exits and the entrance into the fire towers are being replaced. The current
lights are battery operated, and
will be replaced with battery
operated lights on the 4,th, 3rd,
and 2nd floors. The work is
to be completed by an certified electrician. The Program Director will complete a walk-through in 30 days to ensure
compliance.
Person(s) responsible:
Residential Operations Director
Program Director
Timeframe for completion:
Within 30 days
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705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
Based on a physical plant inspection, the facility failed to install a handrail for the steps that lead from the outside basement exit door to the ground floor.
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Plan of Correction
705.10 (a) (l)(iii) Fire Safety
POC: The railing has been
measured and installation
will occur within the next
month. An outside contractor
has been secured to complete
the work. The Program Director will complete a walk-through in 30 days
to ensure compliance.
Person(s) responsible:
Residential Director
Program Director
Timeframe for completion:
Within 30 days
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705.10 (b) (6) LICENSURE Fire safety.
705.10. Fire safety.
(b) Smoke detectors and fire alarms. The residential facility shall:
(6) Maintain all smoke detectors and fire alarms so that each person with a hearing impairment will be alerted in the event of a fire, if one or more residents or staff persons are not able to hear the smoke detector or fire alarm system.
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Observations
Based on a physical plant inspection at 10:45 AM, the facility failed to equip a client bedroom with a detection device or the hearing impaired. The sole room that had a visual alarm for a hearing impaired client was room #10 on the third floor. This room was utilized as a storage room per the label on the door and the discussion with facility staff.
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Plan of Correction
POC: The "hearing impaired"
room is no longer being used
as a storage room. The room
was being utilized as such,
because there were no hearing
impaired clients. However, the
room has been empty of storage
items and reclaimed as a bedroom.
Person(s) responsible:
Residential Operations Director
Lead House Manager
Timeframe for completion: Immediate
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the fire drill schedule and interview with staff, the facility failed to conduct an "unannounced" fire drill in July 2007.
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Plan of Correction
POC: The fire drill schedule
now reflects all unannounced
drills. The schedule has been re-typed reflecting "unannounced" fire drills. The only staff who will be aware of a fire drill will be,
the following:
The Residential Operation Director
The Chef
The Designated Staff-on-Duty
All fire drills will continue to be documented in the Fire Drill Log.
Person(s) responsible:
Residential Operations Director
Chef
Staff-on-Duty
Timeframe for completion:
Within 2 weeks
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711.52(c)(2) LICENSURE Type/Frequency of TX
711.52. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document the type and/or frequency of the treatment and rehabilitation services on the comprehensive treatment plan in three of three client records reviewed, #1, 2 and 6.
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Plan of Correction
POC: With the hiring of a
Clinical Director in July '07,
We are now able to provide
regular clinical supervision
and documented training.
We were able to supplement
clinical supervision with a
LCSW consultant over the
last 3 months. However,
these issues need to be
continually reinforced with
the clinical staff. Therefore,
the Clinical Director will be
providing additional, documented
training to address these
specific areas of non-compliance.
All training sessions will
Be documented and included
In the overall supervision
of the clinical staff. The
Clinical Director will meet
with the Program Director
to discuss completion
of the POC.
Person(s) responsible:
Residential Clinical Director
Program Director
Timeframe for completion:
Within 30 days
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711.52(d) LICENSURE Tx Plan Update
711.52. Treatment and rehabilitation services.
(d) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regimen is less than 30 days, the treatment and rehabilitation plan review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates every 30 days in two of three client records reviewed, #4 and 5.
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Plan of Correction
POC: The Clinical Director
is designing a comprehensive
clinical documentation
training plan for the counselors which will address this specific issue of timeliness. However and as stated above,documentation issues need to be
continually reinforced with the clinical staff and possible barriers to completing the documentation on time addressed, as well.
In addition to the above steps, the Clinical Director will be reviewing each counselors caseload and written documentation, which is due on the Tuesday of the following week, using a weekly/monthly/quarterly monitoring tool to insure documents are completed for both content and timeframes.
Person(s) responsible:
Residential Clinical Director
Timeframe for completion:
Within 30 days
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711.53(c)(2)(ii) LICENSURE Specific Information Disclosed
711.53. Client records.
(c) Confidentiality.
(2) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(ii) The specific information disclosed.
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Observations
Based on a review of client records, the facility failed to comply with the restriction imposed at 4 Pa. Code, Subsection 255.5 (b). The facility did not include the specific information to be disclosed in the consent to release forms in three of four client records reviewed, #1, 5 and 6.
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Plan of Correction
POC: As part of the preceding training
plan, a review of the
5 areas of permitted, regulatory information will be reviewed.
Also, the particular form
in question, will be
standardized to eliminate
any future non-compliance issues.
Person(s)
responsible:
Residential Clinical Director
Program Director
Administrative Assistant
Timeframe for completion:
Within 30 days
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