INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on October 6, 2008 through October 8, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Directions Treatment Services 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 November 7, 2008.
|
Plan of Correction
|
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.
|
Observations
Based on a review of facility training material including the staffing requirements facility summary report on October 7, 2008 and an interview conducted with the Facility Director on October 8, 2008 , the facility failed to establish written individual training plans for all employee's by July 1, 2008.Findings: The 'Staffing Requirements Facility Summary Report' provided verification that thirteen of fifteen staff listed on the staffing requirements summary report, page 8, did not have individual training plans established for the staff development period of July 1, 2008 through June 30, 2009. Facility staff development procedures require an annual written individual training plan be established by July 1, 2008. The last individual training plans established for the thirteen support staff was established on July 1, 2007.
|
Plan of Correction
Training Plans for 2008/2009 (July to June) will be completed by all current employees who do not currently have one. They will be submitted to the Training Officer by October 31 and the satisfactory completion of 2008/2009 Training Plans will be verified by the Program Director on that date. In future training years, the Training Officer will maintain a list of all employees and verify the submission of completed training plans by all employees by their due date of June 30th. This will be verified by the Program Director. |
709.93(a)(11) 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:
(11) Follow-up information.
|
Observations
Based on a review of 8 client records on October 8, 2008, the facility failed to document follow-up attempt information in four of eight client records where required. Findings:Four of eight client records reviewed on October 8, 2008, failed to include documentation of follow-up information. Based on agency policy, follow-up activities are completed thrifty-days after client discharge. Client record #2 - Admitted August 22, 2007, discharged on April 8, 2008 with no follow-up activities documented. Client record #3 - Admitted August 1, 2007, discharged on April 10, 2008 with no follow-up activities documented.Client record #5 - Admitted December 10,2007, discharged on April 17, 2008 with no follow-up activities documented.Client record #6 - Admitted July 3, 2007, discharged on March 11, 2008 with no follow-up activities documented.
|
Plan of Correction
Starting with patients discharged during the month of August 2008, surveys will be mailed out to the last known address. In future months surveys will be mailed at the end of each month to patients who were discharged 2 calendar months prior, i.e. August discharges get October surveys, September discharges get November surveys, and so on. The patients due to receive a survey will be identified from a list generated monthly by a member of the clerical who is already identified and trained. That person will have the responsibility to send out the survey, file a copy in the patient's chart, and replace it with the completed survey if it is returned. The consistent performance of this activity will be overseen by the Clinical Supervisor. |