INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on March 18, 2021 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Casey Recovery LLC 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:
|
Plan of Correction
|
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
|
Observations
Based on a review of documents submitted by the project for the licensing process, the project failed to provide their 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: An assessment of staff training needs.
The project submitted a blank assessment of staff training needs from another facility. The project ' s policy indicates the form will be completed annually in the month of December.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The project director shall ensure that an annual assessment of all staff training needs will be conducted for the upcoming year. Review assessment will be held in December. Training assessments will reflect ASAM information, confidentiality, current treatment trends, medication assisted therapy and DDAP/SCA training offerings. Clinical Supervisor shall provide input as well. |
704.11(a)(2) LICENSURE Overall Training 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:
(2) An overall plan for addressing these needs.
|
Observations
Based on a review of documents submitted by the project for the licensing process, the project failed to provide their 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: An overall plan for addressing staff training needs.
The project submitted a blank assessment of staff training needs from another facility. The project ' s policy indicates the form will be completed in the month of January.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
The project director or designated training officer each shall create a comprehensive staff development program for all staff training needs. As of March 31, 2021 project director will complete overall plan for addressing staff training needs for 2021. |
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.
|
Observations
Based on a review of two personnel records, the facility failed to have CPR certification and first aid training for either staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
Employee #1 was hired on June 8, 2000 as the Project Director and is current in that position. Employee #1 is not currently certified in CPR.
Employee #2 was hired on June 8, 2000 as the Clinical Supervisor and is current in that position. Employee #2 is not currently certified in CPR.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Effective April 8,2021, project director will ensure the facility has at least (1) CPR certified member providing coverage during current program working hours. Project Director will complete CPR re-certification training on April 8,2021. Although the facility is licensed as residential 24 hrs a day, we are currently without a clients. Once we begin to accepting clients we will be fully staffed to requirements to provide to sufficient number of staff persons trained in CPR/First Aid during project onsite hours of operation. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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.
|
Observations
Based on a review of the fire drill record submitted, the facility failed to maintain a written fire drill record including the problems encountered and whether the fire alarm or smoke detector was operative.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Project Director will ensure the Monthly Fire Drill Log includes any problems with the operation of the alarm system, and whether the alarm mode is operative. Fire Drill Log will also note any problems encountered. |
709.32 (c) (6) LICENSURE Medication control
§ 709.32. Medication control.
(6) Medication errors and drug reactions shall be recorded in the client record. This may be the medical record if a separate medical record is maintained for all clients.
|
Observations
Based on a review of the project ' s policy and procedure manual, the project failed to have and implement a written policy and procedure regarding all medications used by clients which shall include medication errors.
These findings were reviewed with project staff during the licensing process.
|
Plan of Correction
Effective March 31, 2021, the Project Director shall amend and implement the policy and procedure manual.
709.32(c)(6) to include medication errors and drug reaction. This update specifically will state "Medication errors and drug reaction shall be recorded in the client record". Director of Nursing will monitor and document in client record any missing dose, wrong medication or wrong dose as well as medication control log. Prescribing Physician will also be notified. |