INITIAL COMMENTS
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This report is a result of an initial on-site licensure inspection conducted on 04/28/2022 by staff from the Bureau of Program Licensure. Based on the findings of the on-site inspection, 517009 Ready Willing & Able Philadelphia/Urban Affairs Coalition was found not to be in compliance with the applicable chapters of 28 PA Code, Chapter 717 which pertains to Recovery House licensing. Therefore, deficiencies were identified during this inspection, and a plan of correction is required.
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Plan of Correction
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§ 717.18(a) LICENSURE Training
§ 717.18. Training.
(a) The licensee shall develop and implement written staff development policies and procedures that identify the person responsible and the time frames for completion of the following:
(1) An assessment of training needs for each staff person and volunteer.
(2) A plan for addressing those needs.
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of staff records, the recovery house failed to have a complete staff record. The recovery house failed to have a mechanism to collect feedback on completed training in four of four records. Staff # 101 was hired on April 10, 2023. Feedback mechanism form not found in the employee record. Staff # 102 was hired on July 05, 2022. Feedback mechanism form not found in the employee record. Staff # 103 was hired on August 17, 2022. Feedback mechanism form not found in the employee record. Staff # 104 was hired on August 24, 2022. Feedback mechanism form not found in the employee record. These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Based on a review of staff records, the recovery house failed to have a complete staff record. The recovery house failed to have a mechanism to collect feedback on completed training in four of four records.
Staff # 101 - has been with RWA 5 days at time of materials request, and 15 days at the time of inspection, therefore had not undergone any training.
Staff # 102
Staff # 103
Staff # 104
In the case of the staff, to which files/submitted information was reviewed, it was made apparent that there is no mechanism for collecting feedback. As well as a staff specific issue, it stems from an organization issue as there is no procedure to address this.
RWA (Executive Director) will create a generic form, to capture staff feedback upon any training received by staff. Such that the form collects the particular details of the training, type, date, and the individual having completed the training, name. The intent of the form would be to create criterial of evaluation with a scoring mechanism 1 - 5 (low - hight), in addition to a comments section.
The designated training lead/sponsor, different session would likely have a different lead/sponsor, would be responsible to distribute and collect the surveys/feedback forms of participants. Passing forms to the Executive Director, the ED will add to the Personnel File/tracking, to monitor completion of both the training requirement and form.
The ED, will also write up the procedure that describes the implementation of the form, as it relates to training, and the over all operating cadence of RWA.
This plan will have a trial run in June, as all RWA staff will participate in Fire Prevention/Safety Training.
Such that it works smoothly/or not, we will tweak accordingly, in anticipation of the next training. |
§ 717.22(b)(2)(i) LICENSURE Beginning of Residency
§ 717.22. Beginning of residency.
(b) The licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
(2) Resident orientation to the drug and alcohol recovery house which must include:
(i) Drug and alcohol recovery house rules, including a method to record residents' expected return time to the drug and alcohol recovery house.
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Observations
Based on a review of resident records, the recovery house failed to have a complete client record. The recovery house failed to have resident orientation acknowledgement in seven of seven records. Client # 101 was admitted on March 30, 2023. Orientation acknowledgement form not found in the client ' s record. Client # 102 was admitted on March 23, 2023. Orientation acknowledgement form not found in the client ' s record.Client # 103 was admitted on February 16, 2023. Orientation acknowledgement form not found in the client ' s record.Client # 104 was admitted on July 27, 2022, and discharged on August 10, 2022. Orientation acknowledgement form not found in the client ' s record.Client # 105 was admitted on November 18, 2022, and discharged on December 16, 2022. Orientation acknowledgement form not found in the client ' s record.Client # 106 was admitted on May 16, 2022, and discharged on August 22, 2022. Orientation acknowledgement form not found in the client ' s record.Client # 107 was admitted on August 22, 2022, and discharged on September 06, 2022. Orientation acknowledgement form not found in the client ' s record.These findings were reviewed with the recovery house staff during the licensing process.
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Plan of Correction
Near term correction 5/26/2023
Client # 101
Client # 102
Client # 103
In each case the Orientation form was signed, however, located at the back of the file.
In each case the documentation has been brought forward and placed behind the Admit form.
Client # 104
Client # 105
Client # 106
Client # 107
In each case, if the form is signed and in the file it will be brought forward in the file and placed behind the Admit form.
In each case, in which the form is neither signed/nor in the file (therefore missing), we have prepared a Missing Document Form, to place at the front of the folder.
MISSING RECORD
This Record is deficient according to:
DDAP PA Code § 717.22(b)(2)(i)
§ 717.22(b)(2)(i)
LICENSURE
Beginning of Residency:
§ 717.22. Beginning of residency. (b) The licensee shall complete the following documentation, which must be signed by the resident, within 24 hours of arrival:
(2) Resident orientation to the drug and alcohol recovery house
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Orientation acknowledgement form not found in the client's record.
Plan for amending process to avoid issue in future 6/30/2023
The recommendation of inspector, is to address how RWA arranges its client record/file. In the month of June RWA will redesign its index which directs case managers to arrange certain records. Guided by the Policy sheet (distributed to Houses in April), the intent is to bring forward DDAP required information, so it sits first in the record, then OAS other needs behind that.
In the specific case of the Orientation Acknowledgement that is both an DDAP and OAS requirement, however, we have been advised that OAS need not duplicate what DDAP already requires, as long as the form is present and signed.
We'd anticipate to create a check list of all forms to be singed/reviewed, such that Case Managers knew that the file is as complete as is the Check List, initialed and dated by both the CM and the Participant.
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