INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the November 7, 2011 and November 9, 2011 licensure renewal inspection. The follow-up inspection was conducted on June 13, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Miners Medical 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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704.5(c) LICENSURE Qualifications for Proj/Fac Dir
704.5. Qualifications for the positions of project director and facility director.
(c) The project director and the facility director shall meet the qualifications in at least one of the following paragraphs:
(1) A Master's Degree or above from an accredited college with a major in medicine, chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 2 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(2) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 3 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
(3) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a specialty in nursing/health administration, nursing/counseling education or a clinical specialty in the human services), public administration, business management or other related field and 4 years of experience in a human service agency, preferably in a drug and alcohol setting, which includes supervision of others, direct service and program planning.
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Observations
Based on a review of the facility personnel records, the facility failed to provide documentation of education major of project director.
The findings included:
The facility personnel records were reviewed. The project director's personnel record was requested for review and not provided so documentation of the education major could not be verified.
Employee #1 - A review of the personnel record indicated that the documentation for educational requirements for the position of project director was insufficient. The documentation indicated that the employee has a BS degree from an accredited college but the major was not listed on the degree.
This is a repeat citation from the November 7, 2011 and November 9, 2011 licensing inspection.
The Project Director confirmed the findings.
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Plan of Correction
The policy for selecting a Project Director has been written up by the Corporate HR Director and will be enforced by the same. The information is verified through ADP and/or Dataline. The documentation for this will be kept in the personnel binder at the Corporate HR department. Process for selection is in accordance with the PA regulations along with other guidelines the Corporation feels the Regional Director needs to have in order to perform in this role. This policy has been written, proper documentation is in the personnel files |
704.11(b)(2) & (3) LICENSURE Basis of Training Plan
704.11. Staff development program.
(b) Individual training plan.
(2) This plan shall be based upon an employee's previous education, experience, current job functions and job performance.
(3) Each individual employee shall complete the minimum training hours as listed in subsections (d)-(g). The subject areas in subsections (d)-(g), with the exception of subsection (g), are suggested training areas. They are not mandates. Subject selections shall be based upon needs delineated in the individual's training plan.
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Observations
Based on a review of employee personnel and training records, the facility failed to document that each employee received an individual training plan based on the employee's previous education, experience, current job functions and job performance in three of three employee records.
The findings included:
Three employee personnel and training records were reviewed. Each employee record was required to have documentation that they received an individual training plan. The records included training plans that were a form being completed as each employee attended training and not a plan for training to be attended.
This is a repeat citation from the November 7, 2011 and November 9, 2011 licensing inspection.
The Project Director was informed of the need for individual training plans to be what is anticipated to occur. The findings were not disputed.
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Plan of Correction
Training plan is completed for the year of 2012 for the overall clinic for general and required trainings. Facility Director will make sure that training is completed and followed through for each employee. An individual section will be added to each employee so that each employee is receiving training to complement their needs and desires to grow in their respective positions. It is the Facility Directors responsibility to make sure that these are properly filled out and completed. The Facility Director will fill out at the beginning of the year all training objectives with signatures and dates. Documentation of completion will be marked on an ongoing basis through the calendar year. Project Director will evaluate on a quarterly basis to make sure these are up to date. |
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 on a review of personnel training records, the facility failed to ensure that all personnel on all shifts are trained upon employment to perform assigned tasks during emergencies in four of four personnel records.
The findings included:
Four personnel training records were reviewed. All personnel records require the documentation of training on assigned tasks during emergencies. The facility failed to document training in four of four personnel records.
This is a repeat citation from the November 7, 2011 and November 9, 2011 licensing inspection.
The Project Director confirmed the findings.
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Plan of Correction
The emergency plan has been updated with specific duties assigned to staff to ensure that evacuation processes will be completed correctly. Training has been completed to bring all staff up to date. The annual training plan has it on its schedule to be reviewed yearly for all existing staff. The employee checklist includes that this training is completed for all new employees that start with the clinic within the first 7 days of hire. Facility Director will ensure that this is completed and documented in the employees personnel binder. |
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 personnel records, the facility failed to provide results of reference checks in one of two personnel records.
The findings included:
Three personnel records were reviewed. Two personnel records were reviewed for reference check results. The facility failed to document the results of reference checks in personnel record # 4.
Employee # 4 was hired on 3/16/2012. A request for reference checks was documented for Dataline on 3/16/2012. The results were not in the record as of the date of the review.
This is a repeat citation from the November 7, 2011 and November 9, 2011 licensing inspection.
The findings were reviewed with the Project Director and confirmed.
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Plan of Correction
Reference checks have been converted to using Dataline as its primary source for verifications. These verifications are placed in the employees files. This is to be completed by the Facility Director and filed prior to hiring of the new employee. |
709.26(d)(4) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(4) Salary information.
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Observations
Based on a review of personnel records, the facility failed to document salary information in one of four personnel records.
The findings included:
Four personnel records were reviewed. All personnel records require the documentation of salary information. The facility failed to document salary information in personnel record # 1. The record was requested for review and not provided so salary documentation could not be verified.
This is a repeat citation from the November 7, 2011 and November 9, 2011 licensing inspection.
The Project Director confirmed the findings.
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Plan of Correction
Salary Documentations were added to employee's files. Annual review by the Facility Director at time of yearly evaluation will include this documentation. Even if no increase in salary is given, the form will be included to show that the process was reviewed. |