INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 2, 2008 and March 7, 2008 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 and a plan of correction is due on April 3, 2008.
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the organizational procedures manual, staff development files and a discussion with the project director on March 7, 2008, an annual evaluation of the overall training plan had not been completed for 2006/2007.
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Plan of Correction
On March 10, 2008 the Project Director updated the goals and objectives for the fiscal year to include an overall annual evaluation regarding the previous year of training and staff development. |
704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on as review of the staffing requirements facility summary report, staff development files, hours of operation, number of facilities, and discussion with the project director on March 7, 2008 the number of staff trained in CPR and First aid is not sufficient to cover two locations and the hours of operation.
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Plan of Correction
One of our part time staff was unable to obtain proof of being trained at a different facility and therefore we were out of compliance. The Executive Director will offer a CPR/First Aid class to all staff held at our facility upon availability of trainer. Consequently, all documentation will be obtained to represent staff members that have been trained. Contact to trainer was made by the Executive Director and no official date was set. This training will be conducted no later than April 30, 2008. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill logs on March 6, 2008 for the period of June 2007 through February 2008, the facility failed to include alternate exit routes in the fire drill record.
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Plan of Correction
On March 7, 2008, the Executive Director changed the Fire Drill Log form to include a section that enables the writer to indicate which exit route was being utilized for our monthly fire drills. This is effectively immediately and new forms will be used beginning March 2008. |
709.93(a)(5) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(5) Progress notes.
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Observations
Based on a review of client records the facility failed to include planning strategies in progress notes. Two of five active client records reviewed on March 7, 2008 failed to include planning strategies in progress notes.
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Plan of Correction
A staff meeting on 3/13/08 at 1 pm was held to include full time clinical staff, the Administrative Assistant and the Executive Director regarding this plan of correction. It was discussed that all clinical staff will continue or begin to write specific plans at the end of each progress note. A memo was given to part time staff on 3/17/08 to assure knowledge of this correction. The Clinical Team Leader and Executive Director will be responsible for assuring compliance during monthly chart reviews for clinical staff. |