INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 8 and 9, 2008 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 January 13, 2009.
|
Plan of Correction
|
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
|
Observations
Based on a review of personnel records, the facility failed to document an assessment of staff training needs for the 2007 training year in three of six personnel records reviewed.
Findings:
Nine personnel records were reviewed on December 8, 2008. Documentation of an assessment of staff training needs was required in six personnel records. The facility failed to document an assessment of staff training needs for three of six personnel records, #4, 7 and 8.
|
Plan of Correction
An Orientation Assessment Training Needs sheet has been designed and implemented for all new hires. The immediate supervisor will be responsible to complete this form, with the new employee, within 30 days of hire. The supervisor will then make a copy of this document for the Administrative Assistant to file in the staff's training folder. This orientation assessment training needs form will be included in the "Supervisor's Checklist" for all new hires. A copy of the checklist will be submitted to the Residential Director for further monitoring.
Person(s) responsible: Immediate Supervisor, Administrative Assistant, and the Residential Director
Timeframe for completion: Within 30 days |
704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of personnel records, the facility failed to document a mechanism to collect feedback on completed training for two personnel records
Findings:
Nine personnel records were reviewed on December 8, 2008. Documentation of a mechanism to collect feedback on all completed training was required in two personnel records. The facility failed to document a mechanism to collect feedback on all completed training for two of two personnel records, #1 and 2.
|
Plan of Correction
The training flow sheet has been amended to include a column for receipt confirmation the training sheet and, when possible, a certificate of training, including the hours. Since training opportunities are approved by supervisors, then supervisors are responsible to monitor submission of all training documents. Once received, a copy will be placed in the staff's training folder. Quarterly audits are completed by the Administrative Assistant and results reported to the supervisors and Residential Director for any further actions. Also, all staff will be reminded, weekly staff meetings and/or supervision, of their responsiblity to submit all training documents within one week of attendance. All staff are to record and assess the training on the MATER Staff Training Form and submit all completed forms, with a certificate, when possible within 7 days to their supervisor.
Person(s) repsonsible: Administrative Assistant, immediate Supervisor, and the Residential Director
Timeframe for completion: within 30 days. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
|
Observations
Based on a review of administrative and training records, the facility failed to document an annual evaluation of the overall training plan for the 2007 training year.
Findings:
The administrative and training records were reviewed on December 8, 2008. The facility failed to provide documentation of the annual evaluation of the 2007 overall training plan.
|
Plan of Correction
The completed assessment has been faxed and placed in the manual. Upon review of the previous year's training, the Program Director will complete the overall annual training assessment and submit the document to the Residential Director for insertion into the P & P manual.
Person (s) responsible: Adminstrative Assistant, Residential Director, and Program Director.
Timeframe for completion: Immediate |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 document that all personnel were trained to perform assigned tasks during emergencies.
Findings:
Nine personnel records were reviewed on December 8, 2008. Training to perform assigned tasks during emergencies was required in four personnel records. The facility did not document the training to perform assigned tasks during emergencies in client records #4, 5, 7 and 8.
|
Plan of Correction
The orientation training form for new hires has been amended to include emergency training within 7 days. The immediate supervisor will be responsible to ensure this training is completed within the timreframe. The required training sheet will be completed by new staff and will be attached to the emergency protocol sheet. All completed sheets will be copied and filed in the staff's training folder.
Person(s) responsible: Immediate Superivsor and Administrative Assistant
Timeframe for completion: Within two (2) weeks |
711.51(b)(6) LICENSURE Psychosocial Evaluation
711.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation for each client.
Findings:
Eight client records were reviewed on December 9, 2008. Psychosocial evaluations were required in four records. The facility failed to document a psychosocial evaluation to include the client's problems/needs, assets/strengths, support systems, negative factors and/or coping mechanisms in four of four client records.
The facility failed to document a clinical assessment of the client's problems/needs and assets/strengths in client records #1, 2 and 3. The facility failed to document a clinical assessment of assets/strengths, support systems and negative factors in client record #4. The facility failed to document coping mechanisms in client records #1, 2, 3 and 4.
|
Plan of Correction
Peer chart audits are being held during weekly team meetings; 5 charts will audited on the last Friday of each month by the Residential Director. An outline of corrections will be distributed to essential personnel for completion/correction no later than the following Wednesday. The Residential Director will provide a training on clinical assessments; identification of strengths and assets. Additional training support will be provided through the Department of Behavorial Health.
Person(s) responsible: Residential Director and Primary Counselor
Timeframe for completion: Within 30 days |
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.
|
Observations
Based on a review of client records, the facility failed to document a treatment and rehabilitation plan update in three of four client records.
Findings:
Eight client records were reviewed on December 9, 2008. Treatment and rehabilitation plan updates were required in four client records. The facility failed to document a treatment plan update for September 2008 and October 2008 in client record #4. The facility failed to document a treatment plan update which was due on December 6, 2008 in client record #2. The facility failed to document an assessment of the client's progress in relationship to the stated goals of the prior treatment plan on the treatment plan update in client record #3.
|
Plan of Correction
A spreadsheet to monitor due dates for clinical documents has been designed and impelmented. The flowchart will be monitored on a monthly basis by the Residential Director. Any missing documents will be communicated to the counselor and expected to be completed by Tuesday of the following week.
The Residential Director will train all clinical staff in the integration of the client's progress or barriers to progress. This training will include reference to previous goals and how to measure if the goals are being met; need to be modified; or have been achieved. Training will occur within 30 days.
Person(s) responsible: Residential Director
Timeframe for completion: within 30 days
The Residential Director will complete a training on assessing client's progress and connecting/reflecting the progress to the treatment plans and progress notes. The training will be documented and placed in the staff's training folder by the Administrative Assistant. Continued assessment of the clinical documentation will on the last Friday of each month by the Residential Director
Perons(s)responsible: Residential Director, Primary Counselor, and Administrative Assistant
Timeframe for completion: within 30 days Director |
711.53(a)(6) LICENSURE Aftercare Plan
711.53. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes all information relative to the client's involvement with the project. In addition to the requirements contained in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plan, if applicable.
|
Observations
Based on a review of client records, the facility failed to document an aftercare plan in one of two client records.
Findings:
Eight client records were reviewed on December 9, 2008. Aftercare plans were required in two client records. The facility failed to document an aftercare plan in client record #8.
|
Plan of Correction
The Residential Director will be conducting weekly monitoring of all clinical charts and documents. As part of this audit, a chart documentation sheet is completed, which includes aftercare plans. Missing documentation will be communicated to the primary counselor and all completed documents must be submitted by Tuesday of the following week. The completed copies are placed in the Discharge binder, the originals are placed in the client's chart.
Also, the Residential Director will train all clinical staff in the timely and proper execution of aftercare plans, including all pertinent information, notification, referrals, continuation of outpatient treatment, importnat contact nubmers,etc.
Person(s) responsible: Residential Director and Primary Counselor(s)
Timeframe for completion: within 30 days from to day's date.
|
711.53(c)(2) LICENSURE Consent to Release Information - Informed/Vol
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:
|
Observations
Based on a review of eight client records, the facility failed to include within the informed and voluntary consent forms the right for clients to verbally revoke the consent.
Findings:
Eight client records were reviewed on December 9, 2008. Informed and voluntary consent forms were required in four client records. The "Consent for Release of Information" form only indicated the client could revoke the consent in writing in four of four client records, #1, 2, 3 and 4.
|
Plan of Correction
All old consent forms have been confiscated from all staff and replaced with the revised consent forms which include "to verbally revoke" the consent. The revised consent forms have been placed in each staff's mailbox and the form book. Also, any old consent forms, in the charts, have been removed and the revised consents signed by the clients.
Person(s)responsible: Residential Director, Primary Counselor, and the Aministrative Assistant
Timeframe for completion: within 30 days |
711.58(a)(2) LICENSURE Drug Storage Area
711.58. Medication control.
When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:
(2) Drug storage areas.
|
Observations
Based on the review of administrative documents and physical plant inspection on December 8, 2008, the facility failed to store the client's methadone under triple lock as per policy.
Findings:
Administrative documents were reviewed on December 8, 2008. The manual required that methadone be stored under triple lock. The physical plant inspection was conducted at 2:00 pm on December 8, 2008. The methadone in individual dose bottles was stored in the nurse's office in a single-locked container.
|
Plan of Correction
A secure lock has been placed on the medicine cabinet. The methadone locked storage box will be locked within the medicine cabinet. The keys are secured with the nurse, Residential Director, and designated staff. This will ensure a triple lock system.
Person (s) repsonsible: Nurse and Residential Director
Timeframe for compeltion: Immediate |
711.58(a)(6) LICENSURE Inventories
711.58. Medication control.
When the drug and alcohol project is not physically located within the parent health care facility, it shall have a written policy regarding medications used by clients, which shall include, but not be limited to:
(6) Inventories.
|
Observations
Based on a review of administrative documents and the physical plant inspection on December 8, 2008, the facility failed to document an inventory of medications.
Findings:
The administrative documents were reviewed on December 8, 2008. The manual stated that the residential director or his/her designee will conduct inventory once a month which will be documented on a Drug Inventory Form. The physical plant inspection was conducted at 2:00 pm on December 8, 2008. The facility failed to provide any documentation of an inventory.
|
Plan of Correction
The Nurse will be responsible to complete the monthly inventory sheet, copy it for the Residential Director; and, secure a copy in the medication room.
The Residential Director will monitor the monthly Drug Inventory Form on the document due flowsheet. The nurse will be notified if the document is missing and will complete the document immediately. The Residential Director will retain all copies in the Drug Inventory chart.
Person(s) responsible: Residential Director and Nurse
Timeframe for completion: Immediate |