INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on January 8 -9, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection James A. Casey House, 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
|
704.7(b) LICENSURE Counselor Qualifications
704.7. Qualifications for the position of counselor.
(a) Drug and alcohol treatment projects shall be staffed by counselors proportionate to the staff/client and counselor/client ratios listed in 704.12 (relating to full-time equivalent (FTE) maximum client/staff and client/counselor ratios).
(b) Each counselor shall meet at least one of the following groups of qualifications:
(1) Current licensure in this Commonwealth as a physician.
(2) A Master's Degree or above from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field which includes a practicum in a health or human service agency, preferably in a drug and alcohol setting. If the practicum did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(3) A Bachelor's Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 1 year of clinical experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience did not take place in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(4) An Associate Degree from an accredited college with a major in chemical dependency, psychology, social work, counseling, nursing (with a clinical specialty in the human services) or other related field and 2 years of clinical experience (a minimum of 3,640 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(5) Current licensure in this Commonwealth as a registered nurse and a degree from an accredited school of nursing and 1 year of counseling experience (a minimum of 1,820 hours) in a health or human service agency, preferably in a drug and alcohol setting. If a person's experience was not in a drug and alcohol setting, the individual's written training plan shall specifically address a plan to achieve counseling competency in chemical dependency issues.
(6) Full certification as an addictions counselor by a statewide certification body which is a member of a National certification body or certification by another state government's substance abuse counseling certification board.
|
Observations
Based on a review of personnel records on January 8, 2019, the facility failed to document two of four staff met the qualifications for the counselor position.Staff #6 was hired for the position of counselor on September 26, 2018. There was no documentation of a transcript to verify the major for the Bachelor degree.Staff #8 was hired for the position of counselor on November 26, 2018, and does not meet the experiential qualifications. These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Employee #6 college diploma did not indicate a specific major. On 1/11/19 we received a copy of individual's transcripts which stated employee's major as Criminal Justice (Acceptable as per Licensing Alert 03-10). On 1/11/19 employee #6 experiential requirements were verified. employee #6 worked at a human services agency providing clinical services, including counseling, from 1/24/16 until 8/30/18 meeting the requirements for the position of counselor.
Employee #8 did not have the required experience and was not qualified for the position of counselor. Employee #8 has been downgraded to the position of counselor assistant. Employee #8's degree is Bachelor of Social Work. Employee #8 has been assigned a supervisor and will be promoted to the position of counselor upon completion of required experience.
The Project Director will be responsible for verifying that all prospective staff member's meet the educational and experiential requirements for their position prior to being hired. The facility Policy and Procedure Manual's Compliance Plan regarding 704.2(a)&(b) will be utilized for all future prospective employees prior to actual date of hire. |
704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
|
Observations
Based on a review of personnel and training records on January 8, 2019, the facility failed to document HIV / AIDS training within one year of hire for two counselor ' s.Staff #3 was hired July 26, 2017, and HIV/AIDS training was due to be completed by July 26, 2018. It was completed late on August 21, 2018.Staff #4 was hired March 27, 2017, and HIV/AIDS training was due to be completed by March 27, 2018. It was not completed as of the date of the inspection.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Clinical Supervisor will be responsible for coordinating and scheduling of employee training, as well as the ongoing monitoring of all staff training . The Clinical Supervisor will ensure, at date of hire, that all staff members who lack HIV/AIDS and/or STD/TB training(s) receive the required training(s) within the stipulated time range in accordance with 704.11(c)(1). As of 01/11/2019 staff #4 is no longer employed at this facility and no longer requires this training. |
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 staff schedules and CPR Certification documentation, the facility failed to provide CPR coverage so that one person trained is onsite during the midnight to 8am shift.Staff schedules from November 19, 2018 to December 9, 2018 were reviewed on January 8, 2019. Staff #9 is scheduled on the midnight to 8am shift for Saturdays and Sundays, and does not have CPR Certification. These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Project Director will ensure that at least one staff member actively certified in CPR will be on duty during all hours of operation. This policy is effective immediately. A staff member currently certified in CPR has been assigned to the midnight to 8AM shift as of 1/11/19. The Project Director will monitor all staff schedule changes to ensure continued compliance with 704.11(c)(2). |
704.12(a)(3)(i) LICENSURE NonHosp Rehab
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(3) Inpatient nonhospital treatment and rehabilitation (residential treatment and rehabilitation).
(i) Projects serving adult clients shall have one FTE counselor for every eight clients.
|
Observations
Based on a review of the current client census information, and the clinical staff hours, the facility failed to ensure the staff to client ratio remained at or below one full time equivalent (FTE) counselor for every eight clients.The current client census information and clinical staff hours were reviewed on January 9, 2019. Based on this information, the staff client ratio is 1:9, which exceeds the required 1:8 ratio.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Project Director will be responsible for ensuring that the facility comply with the Full-time equivalent requirements at all times, in accordance with 704.12(a)(3)(i).
In order to avoid any unforeseen future staffing problems: within two weeks of submission of this POC, the Project Director will submit an exception requesting an increase in Full-time equivalent (FTE) from the current client to counselor ratio of 8:1 to a client to counselor ratio of 10:1.
|
705.10 (a) (1) (i) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the residential facility are unobstructed.
|
Observations
Based on a physical plant inspection conducted on January 9, 2019, the facility failed to ensure the exits from the facility were unobstructed. The door labeled 199 was a key lock dead bolt that could be locked from the inside. When locked, the door would require someone to manually unlock it before exiting, not allowing clients and staff to exit in the event of an emergency. These findings were reviewed with facility staff during the licensing inspection.
|
Plan of Correction
The Project Director is responsible for compliance with all facility safety requirements. The Project director will ensure that the facility maintenance team replaces the building's door marked 199 with a door incorporating a panic bar type assembly as soon as possible. The Project Director will follow up to ensure compliance regarding this door replacement. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
|
Observations
Based on a physical plant inspection conducted on January 9, 2019, the facility did not have operable lights in the stairwell and hallway on the 205 side of the building. Two light bulbs were not working. These findings were reviewed with staff during the licensing inspection.
|
Plan of Correction
On 1/11/19 the facility maintenance team replaced the burned out bulbs in the stairwell and hallway on the 205 side of the building. The Project Director performed a follow-up inspection and the operational check of these lights was good. Within two weeks of submission of this POC the Project Director will develop an inspection policy as well as a checklist document covering all facility areas used by clients and/or staff. Areas inspected will include, but are not limited to, apartments, stairwells, hallways, dayroom area, bathrooms, etc. The house managers will perform and document facility inspections on a weekly basis. The Project Director will maintain a file of all completed inspection documents. If any repairs are needed the Project Director will ensure that the building maintenance team completes repairs in a timely. The Project Director will perform follow-up inspections to ensure all required repairs are completed in a timely manner. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
|
Observations
The facility failed to obtain an informed and voluntary consent from the client prior to disclosure in one of seven client records reviewed on January 9, 2019.Client #6 was admitted to treatment on November 5, 2018. * A release of information for a funding source was signed on November 5, 2018, but failed to indicate the purpose for the disclosure.* Two release of information forms for an agency was signed on November 5, 2018, but failed to indicate the purpose for the disclosure, and if a copy of the consent was offered to the client.* A release of information for an agency was signed on November 7, 2018, but failed to indicate the purpose for the disclosure. "Other" was indicated as the purpose, but no further detail was documented. "Legal Stipulations" was indicated, but this was not a legal agency. The form failed to indicate if a copy of the consent was offered to the client.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
Within two weeks of submission of this POC, the Clinical Supervisor will schedule a confidentiality training session for all current staff members. This training session will include, but will not be limited to, proper documentation policies and procedures.
Upon start of employment and prior to being assigned a caseload (if applicable), the Clinical Supervisor will ensure that all newly hired employees receive confidentiality training including, but not limited to, proper documentation policies and procedures.
In regard to client #6 treatment chart, as of 01/11/2019 all releases of information identified as deficient by the inspector have been corrected by the client's primary counselor. This includes, but is not limited to, purposes of information and that client #6 was offered a copy of these consents. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
|
Observations
Based on a review of client records on January 9, 2019, the facility failed to document written termination notices in two of two client records.Client #1 was admitted on August 6, 2018 and was administratively discharged on October 21, 2018. A written termination notice was not documented in the client record.Client #4 was admitted on October 10, 2018 and was administratively discharged on December 21, 2018. A written termination notice was not documented in the client record.These findings were reviewed with the facility staff during the licensing process.
|
Plan of Correction
The Project Director will ensure that all involuntarily discharged clients will be offered a signed copy of this facility's standardized document entitled Notification of Involuntary Termination. The document includes, among other things, reason(s) for termination as well as a statement that client will have the opportunity to request reconsideration of any decision to terminate treatment. A copy of this document will be maintained in the client's chart. All requests will be in writing and copies of any requests will be maintained in the client' chart. |