INITIAL COMMENTS
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This report is the result of an on-site licensure renewal inspection conducted on November 7, 2011 and November 9, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site 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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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
Based on a review of the facility's policy and procedures, the facility failed to identify the process for the recruitment and hiring of staff persons.
The findings included:
During the onsite inspection of November 7 and 9, 2011, the facility's policy and procedures were reviewed. This review occurred on November 7, 2011. No recruitment policy for staff persons was identified that addressed the recruitment and hiring of staff persons in the written facility policy.
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Plan of Correction
The facility did not identify a staff recruitment policy or procedure. It is the responsibility of the facility to address in writing recruitment and hiring of all employees.
The Human Resources Director is responsible for developing a policy addressing the recruitment of qualified personnel. The facility will make efforts to recruit through State Licensing Job Boards, local newspapers, staffing agencies, colleges and online job search agencies.
The Facility Director will be responsible to implement this policy and insure compliance with the regulation. Under the direction of the facility director, all documentation of qualifications will be placed in the employee's personnel binder within the facility. The Project Director will provide ongoing oversight in this area.
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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:
During the onsite inspection of November 7 and 9, 2011, the facility personnel records were reviewed. This review occurred on November 9, 2011.
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.
The Project Director confirmed only the degree is listed on the documentation. The findings were not disputed.
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Plan of Correction
The facility failed to provide documentation that the Project Director is qualified for the position. It is the responsibility of the facility to demonstrate that personnel are qualified through the inclusion of an official transcript or original diploma that indicates the major related to a pertinent degree. It is the responsibility of the Facility Director to obtain this information and include in the personnel record upon hire. The Human Resources Director will monitor compliance on an ongoing basis. |
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 facility documentation, the facility failed to complete an annual evaluation of the overall training plan for the fiscal year of January 1, 2010 to December 31, 2010.
The findings included:
During the onsite inspection of November 7 and 9, 2011, the annual evaluation of the overall training plan for the fiscal year January 1, 2010, to December 31, 2010, was requested for review.
During a dialogue with the Project Director on November 9, 2011, the Project Director acknowledged that an annual evaluation had not been completed. The findings were not disputed.
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Plan of Correction
The Facility failed to provide the needed documents for the annual evaluation for the overall training plan for the year of 2010 as indicated in704.11. The Project Director has it listed to be completed for the year 2011. Facility Director will follow up with Project Director to ensure that the annual evaluation of training plan is completed by the end of the first quarter of the following year. Annual Evaluation for 2011 will be completed by March 31, 2012. |
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 six of seven employee records..
The findings included:
During the onsite inspection of November 7 and 9, 2011, seven employee personnel and training records were reviewed. Each employee record was required to have documentation that they received an individual training plan. Six of seven records included training plans that were composed of the same form with identical content on all forms.
On November 9, 2011, the Facility Director was informed of the need for individual training plans. 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. Project Director will evaluate on a quarterly basis to make sure these are up to date. The process for the training plan is completed and is effective as of 12/31/2011. |
705.26 (2) LICENSURE Heating and cooling.
705.26. Heating and cooling.
The nonresidential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on a physical plant tour, the facility failed to use only permanently mounted or installed heaters.
The findings include:
During the physical plan tour on November 9, 2011, at 12:30 p.m., two counselor offices contained portable heaters.
The Facility Director confirmed the location of the heaters. The findings were not disputed.
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Plan of Correction
The building was under remodeling for more offices and was contracted to fix the heating and cooling situation. The Facility Director is responsible for the comfort and safety of their staff and will report any discomfort from an employee. Also, a regular building inspection is completed on a quarterly basis with the Health & Safety inspection. If no reports by employees of the discomfort but the inspection conclude that there is an issue, the building owner will be contacted to address the issue immediately. The Facility Director has removed all alternative heating. The Facility Director is responsible to make sure of the comfort and safety of their staff and ensure there are no alternative forms of heating or cooling. |
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 on a review of employee personnel and training records, the facility failed to document that each employee received fire extinguisher training upon employment.
The findings included:
During the onsite inspection of November 7 and 9, 2011, seven employee personnel and training records were reviewed. Each was required to have documentation that they received fire extinguisher training upon employment.
Record # 1 - This employee was hired on 5/9/2011. The facility failed to document fire extinguisher training for this employee.
On November 9, 2011, the Project Director was informed of the need for fire extinguisher training. The findings were not disputed. Fire extinguisher training was documented on 11/9/2011, following the identification of the discrepancy.
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Plan of Correction
The employee that was deficient has been trained on the fire extinguishers and notated in their personnel binder. 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 employee's personnel binder. |
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 records, the facility failed to ensure that all personnel on all shifts are trained upon employment to perform assigned tasks during emergencies in seven of seven personnel records.
The findings included:
During the onsite inspection of November 7 and 9, 2011, seven personnel records were reviewed. This review occurred on November 9, 2011. All personnel records require the documentation of training on assigned tasks during emergencies. The facility failed to document training in seven of seven personnel records.
On November 9, 2011, the Facility Director was informed of the need for emergency training for staff. The findings were not disputed.
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Plan of Correction
The emergency plan has been updated with 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. |
709.22(c)(2) LICENSURE Governing Body
709.22. Governing body.
(c) If the governing body consists of a board, it shall adopt written policies which shall include, but not be limited to:
(2) Qualifications for membership.
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Observations
Based on a review of the facility's policy and procedures, the facility failed to identify qualifications for Board members in the facility policy or By Laws.
The findings included:
During the onsite inspection of November 7 and 9, 2011, the facility's policy and procedures and the corporate bylaws were reviewed. This review occurred on November 7, 2011. No qualifications for membership on the Board were specified in the documentation in the By Laws or in written facility policy.
During a dialogue with the Project Director on November 9, 2011, the Project Director acknowledged that there were no qualifications identified. The findings were not disputed.
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Plan of Correction
A process is being written by the Corporate HR department along with the assistance of the Board of Directors on how one is selected for membership on the Board of Directors. The Board of Directors only meets. The Corporate HR department is responsible for this documentation and will filter the policy and process down to the clinics for their records. The Board of Directors meet every quarter and estimated date for completion will be the end of the 1st quarter. The Human Resource Director will monitor compliance on an ongoing basis. |
709.22(d)(1) LICENSURE Governing Body
709.22. Governing body.
(d) The duties of the governing body include, but are not limited to, the following:
(1) Selecting a project director as the person officially responsible to the governing body.
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Observations
Based on a review of the facility's policy and procedures, the facility failed to identify the process for selecting a project director.
The findings included:
During the onsite inspection of November 7 and 9, 2011, the facility's policy and procedures and the corporate bylaws were reviewed. This review occurred on November 7, 2011. No process for selection of a project director by the Board were specified in the documentation in the bylaws or in written facility policy.
During a dialogue with the Project Director on November 9, 2011, the Project Director acknowledged that there was no process for selection. The findings were not disputed.
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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 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 Project Director needs to have in order to perform in this role. This policy has been written and proper documentation is in the personnel files. The Human Resource Director will monitor compliance on an ongoing basis. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of facility documentation, the facility failed to complete an annual report for the fiscal year of January 1, 2010 to December 31, 2010.
The findings included:
During the onsite inspection of November 7 and 9, 2011, the annual report for the fiscal year January 1, 2010, to December 31, 2010, was requested for review.
During a dialogue with the Project Director on November 9, 2011, the Project Director acknowledged that an annual report had not been completed to provide to the public. The findings were not disputed.
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Plan of Correction
The Facility failed to provide the needed documents for the annual report for the fiscal year of 2010 as indicated in 709.22. The Project Director has it listed to be completed for the year 2011. Facility Director will follow up with Project Director to ensure that the annual report is completed by the end of the first quarter of the following year. Annual Report for 2011 will be completed by March 31, 2012. |
709.23(b)(3) 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:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of facility documentation, the facility failed to complete a performance report to summarize progress towards meeting goals and objectives for the fiscal year January 1, 2010, to December 31, 2010.
The findings included:
During the onsite inspection of November 7 and 9, 2011, the performance report for the summary of goals and objectives for fiscal year January 1, 2010, to December 31, 2010, was requested for review. The report is to be completed at least annually.
During a dialogue with the Project Director on November 9, 2011, the Project Director acknowledged that a performance report had not been completed to include a summary of goals and objectives of fiscal year 2010. The findings were not disputed.
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Plan of Correction
The Facility failed to provide the needed performance report toward meeting goals and objectives for the fiscal year of 2010 as indicated in709.23. The Project Director has it listed to be completed for the year 2011. Facility Director will follow up with Project Director to ensure that the performance report of goals is completed by the end of the first quarter of the following year. The Performance Report of Goals for 2011 will be completed by March 31, 2012. |
709.24(d) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(d) Provisions shall be made, through written agreement with a licensed hospital or physician, for 24-hour emergency psychiatric and medical coverage.
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Observations
Based on a review of letters of agreement, the facility failed to provide documentation of a written agreement with a licensed hospital or physician for 24-hour emergency medical and psychiatric coverage.
The findings include:
The letters of agreement were reviewed on November 7, 2011. No letter of agreement regarding 24- hour emergency medical and psychiatric coverage was documented.
The Project Director and Facility Director were interviewed on this date. The expired written agreement and documentation of the initial contact to update were presented. The findings were not disputed.
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Plan of Correction
The facility failed to provide a Linkage agreement with a hospital for 24/7 psychiatric and medical coverage for our clients. On review we found that the medical agreement with our local hospital lacked the wording to include 24/7 psychiatric and medical care. Facility Director will contact the holder of this linkage agreement and update the services to include 24/7 psychiatric and medical care. A list of required linkages and items to include is placed at the beginning of the binder to ensure that all the agreements meet standards. The Facility Director will review these on an annual basis to make sure all linkage agreements are current and meet the standards outlined. |
709.26(a)(3) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(3) Wage and salary administration.
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Observations
Based on a review of the facility policy and procedures, the facility failed to provide payroll procedures.
The findings included:
During the onsite inspection of November 7 and 9, 2011, the facility's policy and procedures and the corporate Bylaws were reviewed. This review occurred on November 7, 2011. No job classifications or pay scales were provided.
During a dialogue with the Project Director on November 9, 2011, the Project Director acknowledged that there were no job classifications or pay scales. The findings were not disputed.
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Plan of Correction
Payroll scale for the Eastern PA clinics has been created. The Project Director will review this payroll scale on an annual basis to make sure it is comparable to regional standards and expectations. This scale will be given to facilities at each update for their clinic binders. It is completed as of this date and will be reviewed annually and dates notated to show effective dates. |
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 four of seven personnel records.
The findings included:
During the onsite inspection of November 7 and 9, 2011, seven personnel records were reviewed. This review occurred on November 9, 2011. All personnel records require the documentation of reference results. The facility failed to document the results of reference checks in personnel records # 4, 5, 6 and 7.
On November 9, 2011, the Project Director was informed of the absence of the reference check results. The findings were not disputed.
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Plan of Correction
Reference check form has been created for clinic and is used in all new hires for the clinic. The new employee checklist includes documentation and filing of this form. 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 three of seven personnel records.
The findings included:
During the onsite inspection of November 7 and 9, 2011, seven personnel records were reviewed. This review occurred on November 9, 2011. All personnel records require the documentation of salary information. The facility failed to document salary information in personnel records # 1, 2 and 3.
The Project Director was informed of the need for salary information. The findings were not disputed.
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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. |