INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted from April 24-25, 2013, by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Lehigh Valley Drug and Alcohol Intake Unit 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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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based upon the review of the facility's policy and procedures manual and employee records, the facility failed to document reference investigations in accordance with facility policy in two of two employee records reviewed.The findings include:Per the facility's policy and procedure manual, Pennsylvania State Police Criminal History Checks and Child Abuse Clearances are required for all clinical staff, "preparatory to hire."Two employee records requiring documentation of reference investigations were reviewed on April 24, 2013. The facility failed to document reference investigations according to facility policy in records # 3 and 4.Employee # 3 was hired as an Assessment Specialist on April 5, 2012. The Assessment Specialist is a clinical position; therefore, the Pennsylvania State Police Criminal History Check was required, preparatory to hire. The record included documentation of a Pennsylvania State Police Criminal History Check that was late as it was dated April 22, 2013. Employee # 4 was hired as an Assessment Specialist on September 24, 2012. The Assessment Specialist is a clinical position; therefore, the Pennsylvania State Police Criminal History Check was required, preparatory to hire. The record included documentation of a Pennsylvania State Police Criminal History Check that was late as it was dated April 22, 2013. The findings were confirmed by the Executive Director during the exit interview.
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Plan of Correction
Criminal History checks were completed on April 22, 2013 for record number #3, 4.
A new policy was written with implementation set for June 1, 2013 which indicates that the Clinical Director is responsible for all personnel files and the timely completion on human resources duties. The policy dictates that it is the responsibility of the new employee to provide documentation of Criminal History checks and Child Abuse Clearance. New employees will be given a list of required pre-employment documentation. They will be given this list at the time of hire; either in person or via mail. New employees can not start employment until all required documentation is received. It will be the responsibility of the Clinical Director to review all documentation and ensure the required documentation is received on the first date of employment.
The Clinical Director will conduct in-service for all staff on the new policy by May 31 for implementation on June 1, 2013.
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709.28(c)(2) 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:
(2) Specific information disclosed.
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Observations
Based upon the review of client records, the facility failed to adhere to the restrictions specified in 4 PA Code 255.5(b) in one of six client records.The findings include:4 Pa. Code 255.5(b) states: information released to judges, probation or parole officers, insurance company health or hospital plan or governmental officials, under subsection (a)(1), (2), (4), (7) and (8), is for the purpose of determining the advisability of continuing the client with the assigned project and shall be restricted to the following: (1) Whether the client is or is not in treatment. (2) The prognosis of the client. (3) The nature of the project. (4) A brief description of the progress of the client. (5) A short statement as to whether the client has relapsed into drug, or alcohol abuse and the frequency of such relapse.Six client records were reviewed on April 25, 2013. The facility failed to adhere to 4 PA Code 255.5 (b), regarding disclosure of information contained in client record # 6. Client # 6 was evaluated on February 19, 2013. The record included an Evaluation Summary that was dated February 19, 2013, that contained information in excess of restrictions outlined in 4 PA Code 255.5 (b). The record also contained confirmation that the Evaluation Summary was disclosed to the county probation office on February 22, 2012. Therefore, the facility failed to adhere to the restrictions outlined in 4 PA Code 255.5 (b), regarding disclosures made to probation officers.The Clinical Director confirmed the findings.
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Plan of Correction
Clinical Director will inservice the staff on the confidentiality 4 PA Code 255.5 (b) on May 31, 2013 inservice, specifically siting the file on client #6.
Quality Assurance Committe will assure compliance through the quarterly monitoring. Results will be reviewed by the administrative team on a quarterly basis. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based upon the results of the physical plant inspection, the facility failed to ensure that fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.The findings include:The physical plant inspection was conducted on April 24, 2013, from approximately 4:00 PM to 4:20 PM. The facility had two ABC fire extinguishers at the time of inspection. However, the facility failed to have either fire extinguisher inspected within the past year as both inspection tags were dated December 2011.The findings were confirmed by the Clinical Director during the physical plant inspection.
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Plan of Correction
Executive has contacted the Landlord on April 25, 2013, informing him of the inspeciton overdo on the fire extingushers. Maintance man arrived that day with the new company that will be inspecting the fire extinguishers. Executive Director will inspect on a monthly basis to assure that the extinguishers are within the appropriate time frame. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based upon the review of the facility's policy and procedures manual, which included the fire extinguisher training sign-off sheet, the facility failed to document that two of two employees were instructed in the use of a fire extinguisher upon employment.The findings include:The facility's policy and procedures manual, including the fire extinguisher training sign-off sheet, was reviewed on April 25, 2013. The facility failed to document that employees # 3 and 4 were instructed in the use of a fire extinguisher upon employment.Employee # 3 was hired on April 5, 2012, and was to be instructed on how to use a fire upon employment. However, as per the fire extinguisher training sign-off sheet, employee # 3 was not instructed on how to use a fire extinguisher until March 4, 2013.Employee # 4 was hired on September 24, 2012, and was to be instructed on how to use a fire extinguisher upon employment. However, as per the fire extinguisher training sign-off sheet, employee # 4 was not instructed on how to use a fire extinguisher until March 4, 2013.The findings were confirmed by the Clinical Director during the exit interview.
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Plan of Correction
A new policy was written with implementation set for June 1, 2013 which indicates that the Clinical Director is responsible for all personnel files and the timely completion on human resources duties. The policy dictates that the Clinical Director will complete new employee orientation on the first day of employment for all new employees. New employee orientation will include instruction on fire drill procedures, training on the use of fire extinguishers and an in-service on emergency preparedness.
The Clinical Director will conduct in-service for all staff on the new policy by May 31 for implementation on June 1, 2013.
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based upon the review of the facility's policy and procedures manual, which included the emergency training sign-off sheet, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies in two of two records reviewed..The findings include:The facility's policy and procedures manual, including the emergency training sign-off sheet, was reviewed on April 25, 2013. The facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies, specifically, employees # 3 and 4.Employee # 3 was hired on April 5, 2012, and was to be trained to perform tasks in emergencies no later than April 12, 2012. However, as per the emergency training sign-off sheet, employee # 3 was not trained to perform tasks in emergencies until March 4, 2013.Employee # 4 was hired on September 24, 2012, and was to be trained to perform tasks in emergencies no later than October 1, 2012. However, as per the emergency training sign-off sheet, employee # 4 was not trained to perform tasks in emergencies until March 4, 2013.The findings were confirmed by the Clinical Director during the exit interview.
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Plan of Correction
A new policy was written with implementation set for June 1, 2013 which indicates that the Clinical Director is responsible for all personnel files and the timely completion on human resources duties. The policy dictates that the Clinical Director will complete new employee orientation on the first day of employment for all new employees. New employee orientation will include instruction on fire drill procedures, training on the use of fire extinguishers and an in-service on emergency preparedness.
The Clinical Director will conduct in-service for all staff on the new policy by May 31 for implementation on June 1, 2013.
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