INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 20, 2008 through May 21, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, St. John Vianney Center 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 June 24, 2008.
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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 policies and procedures, the facility failed to document a comprehensive staff development program to address the training needs of the project each year. The staff development program did not specify the format in which the annual survey of training needs would take, did not state when the overall training plan would be created and it did not state that each individual staff person was required to complete their own feedback evaluations for the training they attended and when those evaluations would be due.
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Plan of Correction
The COD Director will conduct an annual survey of training needs utilizing a questionair in August, to be completed by September 1.
The COD Director will develop an overall taining plan by Nov30th from the assessment to meet the identified needs for the following calendar year January to December 31.
Staff persons will be required to complete a feedback evaluation for the training they attend. Evaluations will be returned to the COD Program Director within 7 days of attending the training. |
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.
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Observations
Based on a review of personnel and training records, the facility failed to document an assessment of staff training needs in four of eight personnel records reviewed, #5, 6, 7 and 8. The assessment of training needs forms were missing for personnel records #5, 6, 7 and 8.
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Plan of Correction
The Immediate supervisor will work with the employee to develop an individual training plan for the calendar year January to December 31. The Individual Training plan will include the topic, instructor and target date for completion.
The assessment of training needs will be completed upon hire and in August of each year as indicated in the POC for tag 0053. On a quarterly basis the Program Director will conduct an audit of personal records to insure that the Assessment of Training needs is completed and the Individual Training plans are completed
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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.
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Observations
Based on a review of personnel and training records, the facility failed to document the feedback on all completed training in two of two personnel records reviewed, #2 and 3. Employees #2 and 3 attended over 25 hours worth of training but feedback evaluations of the training sessions were documented for four training sessions that totaled only 10 hours.
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Plan of Correction
Staff will be required t complete feedback evaluations for all trainings they attend. Evals will be returned to the COD Program Director within 7 days of the training.
Credit for the tainings will not be noted until the feedback evaluations have been returned to the Program Director.
Program Director will complete a quartely audit of personal records to insure compliance.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel and training records, the facility failed to document complete individual training plans in seven of seven personnel records reviewed, #2, 3, 4, 5, 6, 7 and 8. All of the training plans reviewed did not include the potential resources of the identified training topics. Additionally, the training plans in personnel records #4, 5, 6, 7 and 8 were completed after the due date.
Employee #4 was hired on 11/4/07 but the training plan was not completed until 2/5/08.
Employee #5 was hired on 3/24/08 but the training plan was not completed until 5/20/08.
Employee #6 was hired on 3/10/08 but the training plan was not completed until 5/20/08.
Employee #7 was hired on 2/4/08 but the training plan was not completed until 5/20/08.
Employee #8 was hired on 1/7/08 but the training plan was not completed until 5/20/08.
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Plan of Correction
The immediate supervisor will work with the employee to develop an individual training plan for the calendar year (January to December 31). The individual training plan will include the potential resources of the identified training topics and target date of completion.
The initial training plan for new hires will be completed within 30 days from their date of hire. During the first 90 days of employment the needs of the individual will be assessed by the Immediate Supervisor and the individual training plan will be updated with the individual for the balance of the training (calendar year).
The Program Director will conduct quartely review of personal records to insure compliance. |
705.4 (3) LICENSURE Counseling areas.
705.4. Counseling areas.
The residential facility shall:
(3) Ensure privacy so that counseling sessions cannot be seen or heard outside the counseling room. Counseling room walls shall extend from the floor to the ceiling.
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Observations
Based on an inspection of the physical plant conducted on May 21, 2008, the facility failed to provide a visually private group counseling area. The group counseling area has windows which look into the main hallway of the second floor and were without coverings. While this room is also used as a living room for the clients, it must provide visual privacy when utilized as a counseling area.
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Plan of Correction
The Facility Director will file for an exception to this rule in accordance with the recommendations of the Conference of Catholic Bishops indicating that there should always be visibility into a room where religious and/or clergy are present for any reason. This is supported by most diocese in the USA and since we treat only religious and clergy this recommendation would be important for us to follow.
Effective immediately and until we have a response to our request for an excepiton, we will move our groups to a room that provides the required visual privacy. |
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 records, the facility failed to conduct fire drills at least once a month. The facility documented on the fire drill records that the drills conducted in the months of March (3/31/08) and November (11/30/07) were "silent drills" and no one was evacuated from the building during those drills.
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Plan of Correction
Director of Facilities Management will have actual evacuation fire drills monthly. |
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 a review of the fire drill records, the facility failed to document the specific exit route(s) that were alternated during the fire drills for the following dates: 10/31/07, 12/13/07, 1/24/08, 2/14/08 and 4/29/08.
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Plan of Correction
Director of Facilities Management will conduct staff training(during employees orientations and at yearly safety meetings) to use the appropriate exit doors during drills as well as perform other assigned task during emergencies. Training will be documented by staff sign in sheets and feedback forms for training. Once the location of the fire is announced/known the staff member nearest to that location will vacate that immediate area and direct personnel to a safe exit. The staff member doing the evacuationg will manually log on the Monthly Fire Drill Evaluation Record which exits were used so that we can subsequently use alternate areas for drills.
The Director of Facilities Management will conduct a quartely audit of the Monthly Fire Drill Evaluation Records to insure compliance. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) 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:
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Observations
Based on a review of client records, the facility failed to obtain an informed consent to release information in three of three client records reviewed, #1, 2 and 5. The consents to release only allowed for a written revocation of the consent to release information. The facility must act on any form of a revocation of consent to release information by the client, including verbal revocations.
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Plan of Correction
Consent to release information form has been revised to include the following statement. "I understand that I may revoke this consent upon written or verbal notice (not retroactive) and that the consent will automatically expire one (1) year after the date of my signature. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on a review of client records, the facility failed to document that a copy of the consents to release information were offered to the clients in three of three client records reviewed, #1, 2 and 5.
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Plan of Correction
The Consent to Release Information form has been revised to include the following statement. "I have been offered a copy of this consent to release information form ( )Yes __Initials."
The Program Director will conduct monlty random audits of both open and closed charts to ensure compliance |