INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 26, 2018 through February 27, 2018 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. 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:
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Plan of Correction
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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.
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Observations
Based on a review of personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that 5 employees received the minimum of 6 hours of HIV/AIDS training and at least 4 hours of TB/STD and other health related topics within the regulatory timeframe.Employee #10 was hired as a House Manager on 12/01/15 and was due to have both communicable disease trainings no later than 12/01/17. There was no documentation in the employee file of the completion of the required 6 hours of HIV/AIDS training or the required 4 hours of TB/STD training as of the date of the inspection.Employee #11 was hired as a House Manager on 6/24/14 and was due to have the HIV/AIDS training no later than 6/24/16. There was no documentation in the personnel file of the completion of the required 6 hours of HIV/AIDS training as of the date of the inspection.Employee #12 was hired as a House Manager on 8/22/14 and was due to have the HIV/AIDS training no later than 8/22/16. There was no documentation in the personnel file of the completion of the required 6 hours of HIV/AIDS training as of the date of the inspection.Employee #13 was hired as a House Manager on 10/25/13 and was due to have the HIV/AIDS training no later than 10/25/15. There was no documentation in the personnel file of the completion of the required 6 hours of HIV/AIDS training as of the date of the inspection.Employee #14 was hired as a House Manager on 1/6/15 and was due to have the HIV/AIDS training no later than 1/6/17. There was no documentation in the personnel file of the completion of the required 6 hours of HIV/AIDS training as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All staff members will receive 6 hour HIV/AIDS and 4 hour TB/STD trainings in compliance with 704.11(c). The clinical supervisor will be responsible for ensuring that the house managers/staff members indicated: employees #10, #11, #12, #13, #14 will be scheduled for and complete the identified mandatory training courses no later than 8/27/18. The clinical supervisor will also be responsible for ensuring that all staff members have the required mandatory trainings within the regulatory timeframes. In addition, the clinical supervisor will monitor staff training needs throughout the year to ensure that all staff members have the required trainings scheduled, as needed, and ensure that they attend all scheduled training sessions. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the 8 personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors, in 2 applicable employee records reviewed.Employee #7 was hired as counselor on 3/23/15 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from 1/1/17 through 12/31/17. The employee record documented 16.5 training hours for the training year reviewed.Employee #8 was hired as counselor on 1/25/16 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from 1/1/17 through 12/31/17. The employee record documented 24 training hours for the training year reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor, who also functions as the staff training manager, will regularly review all staff training charts throughout the year to ensure compliance with 704.11(d)-(g). The clinical supervisor will make sure that all staff members are aware of the annual training requirements for their position. |
705.2 (4) LICENSURE Building exterior and grounds.
705.2. Building exterior and grounds.
The residential facility shall:
(4) Store all trash, garbage and rubbish in noncombustible, covered containers that prevent the penetration of insects and rodents, and remove it, at least once every week.
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Observations
Based on a physical plant inspection conducted 2/27/18 between 10:00 am and 12:00 pm, it was observed that the facility failed to maintain all structures on the grounds of the facility so as to be free from any danger to health and safety as the facility had a mound of garbage bags directly outside the rear exit that were not in a covered container or dumpster.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The facility owner will purchase covered trash containers to be used for both trash and recyclables. The trash will continue to be removed weekly. The project director will be responsible for ensuring that the facility is in compliance with 705.2(4) no later than 4/1/18. |
705.8 (2) LICENSURE Heating and cooling.
705.8. Heating and cooling.
The residential facility:
(2) May not permit in the facility heaters that are not permanently mounted or installed.
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Observations
Based on the physical plant inspection on 2/27/18 between 10:00 am and 12:00 pm. the facility failed to ensure that all heaters in the facility were permanently mounted or installed as there was a space heater in bedroom/apartment 1 (the bedroom at the end of the hallway) located on a shelf behind the bed.The findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The space heater identified was removed from the facility. The project director will ensure that all current staff and clients are reminded that these types of heaters are not permitted in the facility. The project director will also ensure all new clients are aware that these heaters are prohibited. All house managers have been notified by the project director to ensure that there are no space heaters in any apartment or in any part of the building during their daily apartment inspections. This policy was implemented immediately 2/27/18. |
709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of 7 client records, 3 client records had treatment plan updates completed after the regulatory timeframe or missing at the time of the inspection.Client #4 was admitted on 10/12/17 and was discharged on 1/16/18. A treatment plan was completed 12/12/17 and the next update was due no later than 1/12/18. However, the update was not completed prior to client's discharge.Client #5 was admitted on 7/19/17 and was discharged on 11/2/17. A treatment plan update was completed 9/17/17 and the next update was due no later than 10/17/17. However, the update was not completed prior to client's discharge.Client #7 was admitted on 3/2/17 and was discharged on 7/19/17. A treatment plan was completed 6/5/17 and the update was due no later than 7/5/17. However, the update was not completed prior to client's discharge.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will ensure that all counselors are aware that treatment plans must be reviewed at last every 30 days. The clinical supervisor will schedule and facilitate a staff training session specifically regarding treatment plan review regulations and program policy. This training session will take place no later than 3/30/18. The project director will provide oversight and will conduct a follow up session with counselors within 2 weeks of the treatment plan training session. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of 7 client records, the facility failed to provide a complete client record in 3 client records.Client #4 was admitted on 10/12/17 and was discharged on 1/16/18. The client record did not contain documentation of follow up information as of the date of the inspection.Client #5 was admitted on 7/19/17 and was discharged on 11/2/17. The client record did not contain documentation of follow up information as of the date of the inspection. Client #6 was admitted on 6/5/17 and was discharged on 9/9/17. The client record did not contain documentation of follow-up information as of the date of the inspection.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The clinical supervisor will ensure that a counselors are aware that the clinical charts of clients who successfully complete the program must contain a standardized follow-up contact document that includes the written consent of the client. A training session regarding the facility follow-up policy and 709.53(a)(11) regulation will be conducted by the clinical supervisor no later than 3/30/18. Oversight and follow-up will be the responsibility of the project director. |