INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted from November 2, 2011 to November 3, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, New Directions 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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705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of the facility fire drill log, the facility failed to document the evacuation routes used for each fire drill and the time taken to do a complete evacuation of the facility for each fire drill.The findings included:During the annual onsite licensure renewal inspection of November 2-3, 2011, Division staff reviewed the facility fire drill log. The log failed to include documentation of the exact time it took to evacuate the facility and the evacuation route used. Documentation of the time the drill took was given as a range (0-5 minutes, 5-10 minutes, etc.). The actual evacuation time and the evacuation route used was missing from the log entries for the following dates in 2011: 1/20/11, 2/28/11, 3/24/11, 4/14, 5/27/11, 6/30/11, 7/27/11, 8/31/11 and 9/30/11. The findings were reviewed with the Project Director and Facility Director and were not disputed.
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Plan of Correction
Fire drills conducted at our facility have used alternate routes and the precise time required for evacuation have been noted for years, however, as the citation correctly points out these have not been properly documented. The form used in the log has since been changed to capture both the evacuation route and the precise time that was required to evacuate the facility. The log reports will continue to be reviewed by the safety committee on a regular basis. |
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 the facility fire drill log, the facility failed to document the evacuation routes used for each fire drill. It was, therefore, not possible to determine if alternate evacuation routes were used at any point during the previous twelve months.The findings included:Division staff reviewed the facility fire drill log during the annual onsite licensure renewal inspection of November 2-3, 2011. The log failed to include documentation of the evacuation routes used. Fire drill log entries which failed to include the evacuation routes used was noted for drills conducted on the following dates: 1/20/11, 2/28/11, 3/24/11, 4/14/11, 5/27/11, 6/30/11, 7/27/11, 8/31/11 and 9/30/11. The findings were reviewed with the Project Director and Facility Director and were not disputed.
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Plan of Correction
While it is not entirely clear why this is cited as a separate item, as noted above the log has been modified to capture this information. |
705.29 (2) (iv) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iv) Secure all hazardous and poisonous substances and materials with safety latches or locks.
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Observations
Based on an inspection of the area designated as the child care area, the facility failed to secure all hazardous and poisonous substances with safety latches or locks. The findings included:Division staff inspected an area designated as the child care area during the annual onsite licensing renewal inspection of November 2-3, 2011. Division staff observed a kitchen base cabinet where cleaning products were stored that was not secured with safety latches or locks. The finding was reviewed with the Project and Facility Director and was not disputed.
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Plan of Correction
A safety latch has already been installed on the cabinet in question. The staff member providing childcare in the room has already been instructed to visually check that the latch is in place whenever children are brought into the room. Instructions have been written directly on the latch instructing anyone who removes it to replace it when they are done. Verifying that the latch is in place has been added as an item on a safety checklist that is part of a facility safety inspection routinely conducted by one of security personnel, which produces a written report. As children are never left in the room unattended, we feel these additional precautions more than adequately address the standard. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on the review of the facility policy and procedure manual and administrative reports on October 31, 2011, the facility failed to document annual goals and objectives which included time frames and available resources.The findings included:The Strategic plan (project goals and objectives) was reviewed for the July 1, 2011 through to June 30, 2012 fiscal year. This plan included goals and objectives, but did not include time frames or resources for the goals and objectives listed. Facility policy required that goals and objectives be formulated on an annual basis. The Strategic Plan was formulated as a three year plan, but without time frames could not be considered as annual goals and objectives.The findings were reviewed with the Project Director, Facility Director, Clinical Director, Clinic Director and staff on November 3, 2011 at approximately 12:30 P.M. and were not disputed.
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Plan of Correction
We do not agree with this finding. Our governing body reviews and approves goals/objectives annually in May of each year. In May of 2012 and in subsequent years, the Project Director will presents to them goals/objectives which will include time frames of less than one year and resources designated for each of the various elements of the plan. |
709.26(d)(1) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(1) The application for employment.
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Observations
Based on a review of the personnel records, the facility failed to ensure that a job application or resume was included in one of two new personnel records reviewed. The findings included:Nine personnel records were reviewed during the onsite licensing inspection of November 2-3, 2011. Two of these records were those of staff hired in 2011. One of two personnel records failed to include documentation of a job application or resume. Personnel record #9- This employee was hired on 5-2-11. At the time that the record was reviewed on 11/2/11, no application or resume was documented. The finding was reviewed with the Project Director and was disputed. The Project Director acknowledged that the document was missing, but felt the sample was too small to justify a citation. The Project Director stated that this was a contract employee, however was not able to produce a copy of that contract.
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Plan of Correction
The hire that precipitated this citation involved some exception circumstances that resulted in a deviation from normal practice. In all future hires we will adhere to existing procedures wherein a Human Resources Assistant verifies at the conclusion of the hiring process that all necessary documents have been signed, if applicable, and included in the personnel file of the new employee and confirms that all the materials to be provided to the new hire, such as a job description, personnel policies, etc., have been provided. Any missing signatures or documents are obtained by the HR Assistant from the person who has conducted the interview, verified references and offered the position, generally a department supervisor. If there are any documents that the HR Assistant is unable to obtain (s)he will notify the Project Director who will take whatever steps are necessary to insure that the personnel file is complete.
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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 on a review of the personnel records, the facility failed to ensure that each new applicant had reference checks documented prior to the date of hire in one of two new personnel records reviewed.The findings included:Nine employee records were reviewed. Two of these records were those of staff hired in 2011. One of two records failed to include documentation of reference checks. Personnel record #9- This employee was hired on 5-2-11. At the time that the record was inspected on 11/2/11, no reference checks were documented. The finding was reviewed with the Project Director and was disputed. The Project Director acknowledged that the document was missing, but felt the sample was too small to justify a citation. The Project Director stated that this was a contract employee, however was not able to produce a copy of that contract.
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Plan of Correction
The hire that precipitated this citation involved some exception circumstances that resulted in a deviation from normal practice. In all future hires we will adhere to existing procedures wherein a Human Resources Assistant verifies at the conclusion of the hiring process that all necessary documents have been signed, if applicable, and included in the personnel file of the new employee and confirms that all the materials to be provided to the new hire, such as a job description, personnel policies, etc., have been provided. Any missing signatures or documents are obtained by the HR Assistant from the person who has conducted the interview, verified references and offered the position, generally a department supervisor. If there are any documents that the HR Assistant is unable to obtain (s)he will notify the Project Director who will take whatever steps are necessary to insure that the personnel file is complete. |
709.26(f)(3) LICENSURE Personnel Management
709.26. Personnel management.
(f) There shall be written job descriptions for project positions which include, but are not limited to:
(3) The requisite skills, knowledge and experience.
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Observations
Based on a review of the personnel records, the facility failed to ensure that each employee job description contained a statement of the requisite skills and experience for the position in one of two personnel records.The findings included:Nine employee records were reviewed during the onsite licensing inspection of November 2-3, 2011. Two of these records were those of staff hired in 2011 One of two personnel records failed to include documentation of the requisite skills and experience on the job description.. Personnel record #9- This employee was hired on 5-2-11. At the time that the record was inspected on 11/2/11, there was no statement of the requisite skills and knowledge for the position on the job description. The finding was reviewed with the Project Director and was disputed. The Project Director acknowledged that the reference to the requisite skills and knowledge for the position was missing, but felt the sample was too small to justify a citation. The Project Director stated that this was a contract employee, however was not able to produce a copy of that contract.
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Plan of Correction
The hire that precipitated this citation involved some exception circumstances that resulted in a deviation from normal practice. In all future hires we will adhere to existing procedures wherein a Human Resources Assistant verifies at the conclusion of the hiring process that all necessary documents have been signed, if applicable, and included in the personnel file of the new employee and confirms that all the materials to be provided to the new hire, such as a job description, personnel policies, etc., have been provided. Any missing signatures or documents are obtained by the HR Assistant from the person who has conducted the interview, verified references and offered the position, generally a department supervisor. If there are any documents that the HR Assistant is unable to obtain (s)he will notify the Project Director who will take whatever steps are necessary to insure that the personnel file is complete. |
715.28(c)(1-5) LICENSURE Unusual incidents
(c) A narcotic treatment program shall file a written Unusual Incident Report with the Department within 48 hours following an unusual incident including the following:
(1) Complaints of patient abuse (physical, verbal, sexual and emotional).
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
(3) Significant disruption of services due to a disaster such as a fire, storm, flood or other occurrence.
(4) Incidents with potential for negative community reaction or which the facility director believes may lead to community concern.
(5) Drug related hospitalization of a patient.
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Observations
Based on the review of facility documentation that included incident reports and staff discussions, the facility failed to provide documentation that incident reports involving patient deaths due to trauma, suicide, medication error or unusual circumstances were sent to the Department of Health. The findings include:The facility provided the discharge client list with reasons for discharge during the November 2, 2011 to November 3, 2011 licensing inspection. Based on the review of this list, it was noted that the reason for discharge for 6 of the patients was due to patient deaths. The facility's internal incident reports from November 2010 to October 2011 were reviewed. There was no documentation alluding to the cause of death for those six patients. All of the deaths occurred while the patients were listed as active clients. The facility failed to document the cause of death for these patients. Death or serious injury due to trauma, suicide, medication error or unusual circumstances must be filed with the Department in the form of an unusual incident report within 48 hours of the event. The facility failed to identify the cause of death and failed to submit the incident report.The findings were reviewed with the Facility Director, Project Director, Clinical supervisor, and clinical team. Facility staff stated that all six of the patient deaths were of natural causes, but could not produce any documentation to substantiate that claim.
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Plan of Correction
The procedure for written reporting of all incidents, unusual or otherwise, has already been changed to require a review by the Facility Director, who will sign off to indicate that an assessment of has been made of the incident to determine if it meets the criteria for reporting under this standard. If it does, a dated signature on the form indicates that an "Unusual Incident Report" form has been completed and faxed to DOH. All staff has already been notified that all deaths of active patients, regardless of circumstances, must generate an incident report. The patient's primary counselor has been assigned the task of generating the report. The counselors have been instructed to include information about the cause of death, if it is known, as well as the source of such information. They have also been instructed to include the same information in a closing note in the patients file. This note may include some additional information that may was not available at the time the Unusual Incident Report was submitted. Additionally, all incident reports are now being scanned into electronic documents to insure easy access and future availability. |
709.91(b)(5) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination, if applicable.
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Observations
Based on a review of client records, the facility failed to ensure that a physical examination completed by a licensed physician was documented in two of twenty patient records.The findings included:Twenty patient records were reviewed during the onsite licensing inspection of November 2-3, 2011. Two patient records did not include documentation of the patient's physical examinations. Patient record # 1- This client was admitted on 4/29/07 and discharged on 12/28/10. There was no documentation of an annual physical examination for 2010. Patient record # 12- The client was admitted on 9/26/11 and last treated on 10/27/11. There was no documentation of an annual physical examination for 2010. The findings were reviewed with medical staff and the Project and Facility directors and were not disputed.
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Plan of Correction
As we believe that the physical examination in question was done and was removed from the file prior to discharge and not returned, we have implemented a policy since whereby other medical personnel will not be able to remove a document from the medical chart without notifying the nursing supervisor. She will insure that a copy is made, with the original being returned immediately or that the document removal is logged with the date and name of the person having the document. Although the physical examination form itself is only done in hardcopy, we will also make a notation in the patient's electronic record that the physical examination was completed. To insure that no annual physical exams fail to be completed, the nursing supervisor and the program physician(s) will review a report to the beginning of each month that lists all of the patients who are due for an annual physical examination in the upcoming month and will insure that they are scheduled. This list will be undated by the nursing supervisor during the month to reflect the examinations as they are successfully completed. Near the end of the month, any patients who have missed appointments and have not met the requirement will be the subject of an intensive effort to insure compliance. The nursing supervisor will confirm to the Facility Director at the end of each month that all required physical examinations have been completed. If there are any that have not been completed, it will be the Facility Director's responsibility to follow up and insure that they are completed at the earliest feasible time.
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709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of patient records, the facility failed to document individualized treatment plans that were consistent with the findings in the psychosocial evaluation in six of twenty patient records. The findings included:Twenty patient records were reviewed during the inspection of November 2-3, 2011. Six of twenty patient records failed to include documentation of individualized treatment goals on the treatment plan that were consistent with the findings listed on the psychosocial evaluation in that patient record. The treatment plans documented in those six patient records were standardized rather than individualized.Patient record # 3- The client was admitted 4/6/11 and last treated on 10/26/11. The comprehensive treatment plan was dated 5/11/11. The treatment plan failed to include goals and objectives which were consistent with the results of the patient's psychosocial evaluation. Patient record #5 - The client was admitted 11/15/10 and last treated on 10/25/11. The comprehensive treatment plan was dated 12/14/10. The treatment plan failed to include goals and objectives which were consistent with the results of the patient's psychosocial evaluation. Patient record #7- This client was admitted on 8/24/11 and last treated on 11/2/11. The comprehensive treatment plan was dated 9/14/11. The treatment plan failed to include goals and objectives which were consistent with the results of the patient's psychosocial evaluation. Patient record # 8- The client was admitted 2/23/11 and last treated on 11/2/11. The comprehensive treatment plan was dated 3/12/11. The treatment plan failed to include goals and objectives which were consistent with the results of the patient's psychosocial evaluation. Patient record # 10- The client was admitted 11/3/10 and last treated on 10/27/11. The comprehensive treatment plan was dated 12/13/10. The treatment plan failed to include goals and objectives which were consistent with the results of the patient's psychosocial evaluation. Patient record # 11- The client was admitted 4/20/11 and last treated on 10/25/11. The comprehensive treatment plan was dated 5/17/11. The treatment plan failed to include goals and objectives which were consistent with the results of the patient's psychosocial evaluation. The findings were disputed by the Project Director but no other relevant documentation for these client records was provided.
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Plan of Correction
The Clinical Supervisor will review the patient files of all newly admitted patients upon the completion of the Comprehensive Treatment Plan to insure that these plans include goals and objectives that are consistent with the results of the patient's psychosocial evaluation. She will address this with individual counselors as required and will alert the Program Director to any continued pattern of deficiency.
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