INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 6-7, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Serento Gardens 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(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 facility's Staffing Requirements Facility Summary Report (SRFSR) and employee records, the facility failed to ensure that each counselor completed at least 25 clock hours of training annually in one of five employee records reviewed.The findings include:The SRFSR and five employee training records were reviewed on November 6, 2013. The facility failed to ensure that employee # 6 completed 25 clock hours of annual training as only 15 clock hours of annual training were documented in record #6.The facility director confirmed the findings.
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Plan of Correction
The Clinical Director spoke to Employee #6, on Monday November 11, 2013, to reinforce the need to complete a minimum of 25 clock hours of training annually.
Counselors are required to monitor their hours and submit to their training folders. Employee #6 was addressed and his Individualized Training Plan was reviewed and reinforced.
The Clinical Director will monitor the traning hours on a quarterly basis to ensure all hours are completed on time. |
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 the physical plant inspection, the facility failed to prohibit heaters that are not permanently mounted or installed. The findings include:The physical plant inspection was conducted on November 6, 2013. During the physical plant inspection a portable space heater was observed on top of a file cabinet in the discharged record storage area. The facility director confirmed the findings.
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Plan of Correction
On November 7,2013 the portable space heater was removed from the physical plant by the Facility Director.
The Facility Director will monitor and ensure that portable space heaters are not present within the physical plant at any time. |
705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the physical plant inspection, the facility failed to ensure that all fire extinguishers were inspected and approved annually by the local fire department or fire extinguisher company.The findings include:The physical plant inspection was conducted on November 6, 2013. The facility failed to ensure that all fire extinguishers were inspected and approved annually as two fire extinguishers did not have inspection tags and five fire extinguishers had expired inspection tags that were dated January 2012. The facility director confirmed the findings.
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Plan of Correction
On November 6, 2013 the Facility Director contaced Cintas to schedule an appointment for inspection.
On November 7, 2103 Cintas completed an inspection of all fire extinguishers contained within the physical plant. Additionally, the Facility Director opted to have an additional fire extinguisher installed on the second floor.
The Facility Director will monitor and oversee that all fire extinguishers are inspected and properly tagged on an annual basis.
As of Friday November 8,2013 all fire extinguishers were inspected and properly tagged. |
709.94(c) LICENSURE Project management services
709.94. Project management services.
(c) A telephone number shall be displayed conspicuously to the general public for emergency purposes.
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Observations
Based on the physical plant inspection, the facility failed to display a telephone number that can be accessed by the general public in case of an emergency.The findings include:The physical plant inspection was conducted on November 6, 2013. The facility failed to conspicuously display a telephone number to the general public for emergency purposes.The findings were confirmed by the facility director.
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Plan of Correction
On November 6, 2013 the Clinical Director requested that a support staff person create a sign to include a telephone number to the general public for emergency purposes.
This sign was conspiciously hung in the front window of the facility's entrance.
The Clinical Director will monitor on a daily basis that the sign is not removed.
As of Friday November 8,2013 a sign was hung in the front window of the facility's entrance which includes the telephone number to the general public for emergency purposes. |