INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, 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, a review of the facility summary report, and a discussion with the facility director, the facility failed to provide documentation of TB/STD training for three of fifteen personnel.
The findings include:
Two personnel records were reviewed on May 9, 2011. The facility summary report was reviewed on May 10, 2011. Fifteen personnel were required to have documentation of HIV/AIDS and TB/STD training. The facility did not provide documentation of the required HIV/AIDS and TB/STD training for personnel records # 8, 9, 10, 11, 12, 13, 14.
Employee #13 is a staff nurse and was hired November 13, 2006. HIV/AIDS and TB/STD training was to be completed within two years of hire, November 13, 2008. The facility failed to provide documentation of TB/STD training.
Employee #14 is the director of nursing and was hired August 11, 2008. HIV/AIDS and TB/STD training was to be completed within two years of hire, August 11, 2010. The facility failed to provide documentation of TB/STD training.
Employee # 16 is a counselor and was hired January 4, 2010. HIV/AIDS and TB/STD training was to be completed within one year of hire, by January 4, 2011. The facility failed to provide documentation of TB/STD training.
Employee # 17 is a counselor and was hired August 13, 2009. HIV/AIDS and TB/STD training was to be completed within one year of hire, by August 13, 2010. The facility failed to provide documentation of HIV/AIDS training.
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Plan of Correction
The three employees that need TB/STD will be completed by 8/2011 and the employee missing HIV/AIDS will have the training completed by 8/1/2011. All four employees will complete the trainings through BDAP approved listings.
The Director of Nursing will track all nursing staff trainings to ensure that they have meet all requirements. Copies of the trainings will be maintained in the training manuals.
Clinical Supervisors will track all clinical trainings to ensure that they have meet the requirements. Copies of the trainings will be maintained in the training manuals.
Direct supervisors will track from the date of hire all new staff to ensure they have completed all required trainings within the appropriate timeframes. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection and an interview with facility staff, the facility failed to ventilate a staff bathroom by an exhaust fan or window.
The findings include:
A physical plant inspection was conducted with the counselor responsible for over seeing the physical plant inspections monthly on May 11, 2011, at approximately 11:45 AM. Per regulation, the nonresidential facility shall ventilate bathrooms by exhaust fan or window. The facility has several bathrooms for both staff and patient use. One bathroom is located in a hallway that does not have any windows; this bathroom has an exhaust fan in the bathroom which is no longer operative.
The facility counselor confirmed the exhaust fan in the staff bathroom is not operative.
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Plan of Correction
The company has approved money in the facilities budget to have the four bathrooms in the main building updated including new ventilation. Three estimates have already been submitted by licensed contrators. The Regional Director will sign off on work order in order for the work to be completed by 12/31/2011.
The staff bathroom with the non-working ventilation will be addressed by a licensed contractor by 7/15/2011. Clinic Director will ensure that the contractor completes the job by 7/15/2011. |
709.32(b) LICENSURE Medication Control
709.32. Medication control.
(b) Verbal medication orders may be accepted but shall be put in writing and signed within 24 hours thereafter by the prescribing physician.
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Observations
Based on a review of client records and discussion with medical staff, the facility failed to ensure the physician signed verbal orders as required.
The findings include:
Twenty one client records were reviewed May 10-12, 2011. Two client records reviewed contained documentation of the physician issuing a verbal order. One of the two client records had two different verbal orders issued by the physician that were not signed within the required 24 hours.
Client # 8 was admitted on January 6, 2011. The physician issued a verbal order for an increase on January 7, 2011. The verbal order was signed by the physician on January 11, 2011. The physician issued a verbal order on January 8, 2011 and signed the order on January 11, 2011.
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Plan of Correction
Beginning on July 1, 2011, all verbal orders will be scanned or faxed to the Medical Director to sign and send back to the facility when he is not physcially in the office. The Director of Nursing will ensure that all verbal orders are sent to the Medical Director for his signature as well as signed and dated by the Medical Director within 24 hours. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on the review of client records, the facility failed to execute an evaluative composite picture of the client in relationship to the collected historical data in four of five client records.
The findings include:
Twenty two client records were reviewed May 9-11, 2011. Five client records were reviewed for the psychosocial evaluation of the historical data collected.
Client # 4 was admitted March 17, 2011. The psychosocial was a repeat of the data as reported by the client.
Client # 7 was admitted April 1, 2011. The psychosocial was a repeat of the data as reported by the client.
Client # 8 was admitted January 6, 2011. The psychosocial was a repeat of the data as reported by the client.
Client # 15 was admitted February 1, 2011. The psychosocial was a repeat of the data as reported by the client.
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Plan of Correction
All psychosocial assessments will be reviewed by Clinical Supervisors prior to be filed in the patient chart to ensure that the Counselors have provided their clinical impressions of the patient and not solely what the patient reported. There will be a training conducted by the Clinical Supervisors by 7/8/2011 to provide specific examples of well written detailed psychosocial assessments that contain a complete evaluative composite of the patient. |