INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 10, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Conewago Pottsville 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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704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of seven personnel records, the facility failed to ensure that one counselor assistant was given a written semiannual performance evaluation based upon measurable performance standards.
Employee # 6 was hired on February 20, 2023 as a counselor assistant. Employee #6 did not receive a semiannual performance evaluation in the last year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
During the time frame that the one counselor assistants' semi-annual evaluation was due to be completed there were some adjustments being made to the company's evaluation forms and the corrections were not completed at the time the evaluation was due. As of 7/15/2024 the adjustments have been made and the new evaluations forms are now available to all facilities in the company's KRONOS system. To ensure compliance with the semi-annual and annual evaluations due dates the KRONOS system will notify the employee when their semi-annual and annual self - evaluations are due. Once the employee completes their self ? evaluation then the KRONOS system will notify the Facility Director that the semi annual and the annual evaluation is due to be completed for each employee. |
705.7 (b) (6) 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:
(6) Store all food items off the floor.
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Observations
Based on a physical plant inspection, the facility failed to store all food items off the floor. During the physical plant inspection on July 10, 2024, it was observed that a crate of bread items was directly on the floor in the kitchen.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/10/2024 the kitchen staff were retrained in regards to food storage. The areas covered with the kitchen included food preparation and specifically food storage as to no food items maybe stored on the floor. All food items will be stored on the shelving up off of the kitchen floor area at all times. To ensure future compliance the Facility Director will tour the kitchen area on a weekly basis. |
709.24 (a) (3) LICENSURE Treatment/rehabilitation management.
§ 709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
(3) Written procedures for the management of treatment/rehabilitation services for clients.
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Observations
Based on a review of client records, the facility failed to follow their written procedures for the management of treatment/rehabilitation services for not following their policy on when treatment plans are updated in five out of seven records reviewed. The facility ' s policy and procedures manual stated that the initial treatment plan update is completed at fifteen days and then every thirty days thereafter. Additionally, the facility failed to follow their policy on when discharge summaries are completed in three out of four applicable records reviewed. The facility ' s policy and procedures manual states that discharge summaries are completed within 5 days of discharge.
Client #2 was admitted on May 22, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was completed on May 29, 2024 and the update was due no later than June 13, 2024; however, it was not completed until July 9, 2024.
Client #4 was admitted on December 6, 2023 and discharged on February 5, 2024. A comprehensive treatment plan was completed on December 14, 2023 and the update was due no later than December 28, 2023; however, it was not completed until January 18, 2024. A discharge summary was due no later than February 10, 2024; however, it was not completed until February 14, 2024.
Client #5 was admitted on October 19, 2023 and discharged on November 17, 2023. A comprehensive treatment plan was completed on October 25, 2023 and the update was due no later than November 8, 2023; however, it was not completed until November 14, 2023. A discharge summary was due no later than November 22, 2023; however, it was not completed until December 14, 2023.
Client # 6 was admitted on April 4, 2024 and discharged on May 6, 2024. A comprehensive treatment plan was completed on April 13, 2024 and the update was due no later than April 27, 2024; however, it was not completed until May 3, 202. A discharge summary was due no later than May 11, 2024; however, it was not completed until May 30, 2024.
Client #7 was admitted on December 13, 2023 and discharge on January 12, 2024. A comprehensive treatment plan was completed on December 18, 2023 and the update was due no later than January 1, 2024; however, it was not completed until January 11, 2024.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
On 7/12/2024 the Clinical staff was retrained in the areas of treatment plans as well as discharge summaries. The areas that were covered in the training included content of the treatment plans and discharge summaries as well as the due dates of each treatment plan and discharge summary. The specific due dates covered for the treatment plans was the initial treatment plan update is due at fifteen days and then due every thirty days thereafter. In regards to the content covered for the due dates for the discharge summary staff was trained that the discharge summary is due no later than five days after discharge as to policy. To ensure future compliance the treatment plans and discharge summaries will be audited on a monthly basis by the Firetree compliance team to ensure they are completed in the proper time frame. |