INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 4, 2011 and August 5, 2011 by staff from the Division of Drug and Alcohol 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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709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on an interview with the Project Director and a letter from the Controller, the project failed to document the completion of an independent annual audit of financial activities by the end of the the project's fiscal year.The findings include:The Project Director was interviewed on August 5, 2011 and confirmed that an independent annual audit of financial activities has not been completed since June 24, 2010, which was for the fiscal year July 1, 2008 through June 30, 2009. The inspector was also presented with a letter from the Controller of Firetree, Ltd that indicated the 2010 audit was late and had not yet been completed as of August 8, 2011.
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Plan of Correction
Project director will review DOH standard 709.25(a) relating to the completion of an independent annual audit with governing body of Firetree, Ltd. on 8/29/11 to ensure their understanding.
Project director will secure the 2010 audit from the governing body by 9/30/11.
Governing body will secure completion of subsequent annual audits within six months following the end of the project's fiscal year to ensure ongoing compliance. |
705.2 (2) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well-being of residents, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based on a physical plant inspection and a conversation with a counselor, the facility failed to keep the building in good repair at all times. The findings include: A physical plant inspection was conducted on August 5, 2011 from 9:30 am to 10:20 am. A piece of drywall, measuring approximately 18" x 5" was missing from the outside of the shower assigned to the men's detox unit. At 9:51 am conversation was held with a counselor and she confirmed the facility was aware of the hole as a work order had already been submitted.
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Plan of Correction
Facility director had the maintenance man repair the wall in question on 8/23/11.
Project director will review the importance of maintaining the facility in a safe, clean manner with the facility director during the weekly clinical meeting on 9/1/11.
Facility director will monitor the ongoing condition of the physical plant of the facility by conducting a daily walk through inspection of the facility beginning 9/2/11 and report any needed repairs to the governing body during the weekly director's meeting beginning 9/5/11. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection and a conversation with a dietary staff member, the facility failed to ensure all garbage was stored in a covered container. The findings include: A physical plant inspection was conducted on August 5, 2011 from 9:30 am- 10:20 am. An uncovered plastic garbage can was positioned near the rear of the kitchen. During a conversation with a dietary staff member at 9:58 am it was confirmed that this trash can did not have a lid and it is regular practice for it to be uncovered.
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Plan of Correction
Project director had the facility director purchase and place a new garbage can with the appropriate lid in the kitchen and remove the can without the lid the day of the inspection 8/5/11.
Project director will review the DOH physical plant standards with the facility director on 9/1/11 during the weekly clinical meeting to ensure her understanding.
Facility director will monitor ongoing compliance by conducting daily walk through inspections of the facility beginning 9/2/11. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records and an interview with the project director, the facility failed to ensure fire extinguisher training was provided upon employment in one of eight personnel records reviewed. The findings include:On August 4, 2011, eight personnel records were reviewed for documentation that fire extinguisher training was provided upon employment. The facility did not document that fire extinguisher training was provided upon employment in personnel record # 7.Employee #7 was hired on July 12, 2010 but the training certificate indicated this training occurred on September 12, 2010. On August 4, 2011 the project director also viewed employee #7's record and confirmed the date the fire drill training was documented.
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Plan of Correction
Project director will retrain the facility director on the appropriate completion and documentation of employee fire extinguisher/fire safety training during the weekly clinical meeting on 9/1/11.
Corporate training officer will monitor ongoing compliance through the maintenance of the employee software system the project utilizes by 9/2/11. |
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.
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Observations
Based on the review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform tasks during emergencies. The findings include:On August 4, 2011, eight personnel records were reviewed for documentation of emergency training. The facility did not document that emergency training was provided upon employment in personnel record # 7.Employee #7 was hired on July 12, 2010, employee #7 should have been trained for emergencies by July 19, 2010. The training certificate indicated this training occurred on September 12, 2010. On August 4, 2011 the project director also viewed employee #7's record and confirmed the date the emergency training was documented.
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Plan of Correction
Project director will retrain the facility director on the appropriate completion and documentation of employee emergency procedures training during the weekly clinical meeting on 9/1/11.
Corporate training officer will monitor ongoing compliance through the maintenance of the employee software system the project utilizes by 9/2/11. |
705.10 (d) (6) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(6) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on the review of the fire drill log, the facility failed to document the use of alternate exits during fire drills in eleven out of the twelve months reviewed. The findings include:On August 4, 2011, the fire drill log was reviewed for the period covering July 2010 to June 2011. The section on the form that specifies: Evacuation Path, was filled out by facility staff to read: "All Rear Doors", during the drills conducted for July 2010, August 2010, September 2010, October 2010, November 2010, January 2011, February 2011, March 2011, April 2011, May 2011, and June 2011. The inspector was unable to determine which exits had been used and if they were alternating based on the way the form was completed. On August 4, 2011, the project director and director of quality assurance both confirmed the documentation recorded in the fire drill log.
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Plan of Correction
Project director will retrain the facility director on the appropriate completion and documentation of the facility's monthly fire drills on 9/1/11; specifically addressing the importance of utilizing alternate exits and holding the drills at various times of the day.
Corporate compliance officer will monitor ongoing compliance through monthly review of the facility's fire drill ledger by 9/2/11. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility's policy and procedures, and a conversation with the director of quality assurance, the facility failed to document follow-ups in accordance with the facility's policies and procedures.The findings include:Four inpatient records were reviewed on August 6, 2011. Documentation of a follow-up was required in two of those records. The facility failed to document a follow-up in accordance with the facility's policies and procedures in one of two records reviewed, specifically, client record #7. The facility's follow-up policy states: When a client is discharged and referred to an outside resource, the facility will contact the resource within one week from the date the referral is to be completed. If a client is not referred, the facility will attempt to contact the client within 30 days after discharge. Client # 7 was admitted on April 20, 2011and discharged on May 5, 2011. The client was not referred to an outside source. A follow up attempt should have been made to the referral source by June 5, 2011, no follow up attempt had been documented for client #7. The missing follow-up attempt had been confirmed with the director of quality assurance as he was asked to provide verfication of the completed follow-up and was unable to find it.
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Plan of Correction
Project director will retrain all facility staff on the appropriate completion of the facility's follow up procedures during the weekly clinical meeting on 9/1/11.
Facility director will monitor compliance on a weekly basis during regular clinical chart reviews by 9/2/11 and corporate compliance officer will assist through the completion of his monthly clinical chart reviews by 9/30/11. |
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 the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS and at least 4 hours of TB/STD and other health related topics within the first year of employment for clinical staff and within two years of employment for non-clinical staff. The findings include: On August 4, 2011 eight personnel records were reviewed. The facility failed to document the required training hours in one of of eight personnel records, specifically employee # 7. Employee # 7 was hired on July 12, 2010,STD/TB training was due by July 12, 2011. As of the date of the licensing inspection, there was no documentation of this training for employee #7. Both the project director and director of quality assurance consulted with employee #7 staff to determine if the STD/TB training had been taken. Employee # 7 confirmed the training had not yet been taken.
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Plan of Correction
Project director will retrain the facility director on the appropriate completion and documentation of employee TB/STD training on 9/1/11 to ensure her understanding.
The employee in question is scheduled to participate in TB/STD training on 9/29/11. A training certificate will then be placed in the employee's personnel file and documented in the project's employee software program to demonstrate completion.
The corporate training officer will monitor ongoing compliance through the maintenance of the employee software program the project utilizes. |
704.12(a)(1)(i) LICENSURE Client/couns ratios
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(1) Inpatient nonhospital detoxification (residential detoxification).
(i) There shall be one FTE primary care staff person available for every seven clients during primary care hours.
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Observations
Based on a review of Staffing Requirements Facility Summary Report, and interviews with the project director and director of quality assurance, the facility failed to ensure that the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every seven clients.The findings include:The current client census information and clinical staff hours were reviewed on August 4, 2011. Per regulation, inpatient nonhospital detoxification (residential detoxification) projects serving adult clients shall have one FTE counselor for every seven clients. On July 29, 2011, from 12 am to 6 am, there was one staff member on duty and a census of 14 clients, based on this information, the client to staff ration is 14:1; this ratio status exceeded the required 7:1 ratio. On July 30, 2011 from 12 am to 6 am there was one staff member on duty and a census of 12 clients, based on this information, the client to staff ration is 12:1, this ratio status exceeded the required 7:1 ratio.On August 2, 2011 from 2 am to 5 am there was one staff member on duty and a census of 13 clients, based on this information, the client to staff ration is 13:1, this ratio status exceeded the required 7:1 ratio.The project director and director of quality assurance were interviewed on August 4, 2011 at 10 am. They confirmed the ratios recorded on the Staffing Requirements Facility Summary Report.
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Plan of Correction
Project director reviewed the staff/client ratios for detox with the governing body on 8/29/11 to ensure their understanding and administrative support.
Project director will review the staffing standard with the facility director during the weekly clinical meeting on 9/1/11 to ensure her understanding.
Facility director will schedule the appropriate staffing level and review staffing patterns with the governing body on a weekly basis beginning 9/2/11 to ensure compliance.
Corporate compliance officer will monitor staffing patterns monthly by 9/30/11 to ensure ongoing compliance. |