INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 27-28, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Recovery Revolution, Inc. 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 the Staffing Requirements Facility Summary Report, and an interview with the Project Director, the facility failed to ensure that one of two staff persons received 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.
The findings include:
The Staffing Requirements Facility Summary Report was reviewed on January 27, 2014. Two employees were required to have documentation of HIV/AIDS and TB/STD training. The facility failed to ensure that employee # 7 received the required HIV/AIDS and TB/STD training.
Employee # 7 was hired on June 1, 2010 as an administrative assistant. HIV/AIDS and TB/STD training was to be completed by June 1, 2012. As of January 27, 2014, the facility failed to ensure that employee # 7 received both trainings.
The Project Director confirmed the findings.
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Plan of Correction
The Executive Director is responsible for the individualized training plan as well as the agency training plan for all staff members thus will be responsible for the implementation of mandatory trainings. As of February 25th, the training form that is in the staff training requirements that is signed upon hire date has been updated to include this regulation. In addition, any employee that is currently on staff that is in need of this training will be attending the next available HIV (6hr) and STD/TB (4hr) training in Allentown, PA which the staff that is in question is schedule for on April 8th and April 15, respectively. The training lists for our area are released every six months. The Executive Director reviews with each staff member and signs them up for the trainings. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on observation during the physical plant inspection, the facility failed to ensure that there were no portable heaters that were not permanently mounted or installed within the facility.
The findings include:
A physical plant inspection was conducted on January 28, 2014 at approximately 10:15 AM and 12:15 PM. Two portable space heaters that were not permanently mounted or installed were observed in the basement.
The Project Director acknowledged the presence of the portable space heaters.
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Plan of Correction
Quarterly, the Executive Director does a physical plant walk thru to ensure safety and proper maintenance of the building. In addition, all the staff have been aware for several years that space heaters are not allowed to be used in office space and there has been no use of them since 2011. As of February 25, 2014 at 3:15 PM, the two space heaters in the locked basement storage were removed off the premises entirely by the Executive Director. The Executive Director removed them personally and is responsible to ensure that they are not on the premises. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observation during a physical plant inspection, the facility failed to light interior exits and stairs at all times, failed to clearly indicate exits by the use of signs, and failed to ensure that exits from rooms and from the nonresidential facility are unobstructed.
The findings include:
A physical plant inspection was conducted on January 28, 2014 at approximately 10:15 AM and 12:15 PM. The facility was utilizing the basement for storage. It was observed that the basement had two exits; however, the facility failed to indicate either exit by the use of signs. In addition, the interior of the second exit/storm cellar door was not lighted during the hours of operation, and the exterior of the second exit/storm cellar door was covered with snow and blocked by a car.
The Project Director confirmed the observations made by the Licensing Specialist.
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Plan of Correction
The light bulb in the basement near the exit had burned out by the storm cellar exit and was changed on 1/29/14. In addition, all snow was removed from the storm cellar door exit and remains clear. The Executive Director installed exit signs that are illuminated by lights going out to the storm cellar exit on 3/23/14. Pictures of the changes have been sent to the department for review. The facility will maintain a buffer zone of at least 3 feet at the top of the "bilco doors" for exiting purposes. Recovery Revolution has notified the person who shovels the sidewalks and plows the back lot to ensure that they include the storm cellar exit. The Executive Director will do a monthly walk through of the building assuring all exits are cleared and all light bulbs are in working order. |
709.81(b)(6) LICENSURE Intake and admission
709.81. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation in two of two client records.
The findings include:
Two client records requiring documentation of a psychosocial assessment were reviewed on January 28, 2014. The facility failed to document a psychosocial evaluation in client records # 1 and 2.
Client records # 1 and 2 included a standardized form identified as a psychosocial evaluation. The facility failed to include an evaluative component to the psychosocial evaluation contained in client records # 1 and 2. Instead, the standardized form consisted of a checklist of items to be circled by the clinician.
The findings were reviewed with the Project Director.
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Plan of Correction
A section on the psychosocial evaluation for was changed to include the questions "Clinical Impressions of Client: Summarize how this data impacts the clients functioning and how will this impact treatment with our agency?" The Executive Director will hold a mandatory clinical staff meeting on 3/25/14 at 1 PM to train staff on the new form. We will be using this form for all new intakes beginning 9 AM on 3/26/14. The clinical supervisor will randomly select charts from each member of clinical staff to assure that they are being filled out properly in the next 6 months. |
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 a review of client records, the facility failed to document a psychosocial evaluation in eight of eight client records.
The findings include:
Eight client records requiring documentation of a psychosocial evaluation were reviewed on January 27-28, 2014. The facility failed to document a psychosocial evaluation in client records # 1, 2, 3, 4, 5, 6, 7 and 8.
Client records # 1, 2, 3, 4, 5, 6, 7 and 8 included a standardized form identified as a psychosocial evaluation. The facility failed to include an evaluative component to the psychosocial evaluation contained in client records # 1, 2, 3, 4, 5, 6, 7 and 8. Instead, the standardized form contained a checklist of items to be circled by the clinician.
The findings were reviewed with the Project Director.
This is a repeat citation. The facility was previously cited for non-compliance on 3/7/13.
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Plan of Correction
A section on the psychosocial evaluation for was changed to include the questions "Clinical Impressions of Client: Summarize how this data impacts the clients functioning and how will this impact treatment with our agency?" The Executive Director will hold a mandatory clinical staff meeting on 3/25/14 at 1 PM to train staff on the new form. We will be using this form for all new intakes beginning 9 AM on 3/26/14. The clinical supervisor will randomly select charts from each member of clinical staff to assure that they are being filled out properly in the next 6 months. |