INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 27 & 28, 2013 by staff from the Department of Drug and Alcohol Programs, Program Licensure Division. Based on the findings of the on-site inspection, Wyoming Valley Alcohol and Drug Services 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 upon the review of employee training records, the facility failed to provide documentation of a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum in two of four records. The findings include:Four records requiring documentation of mandatory HIV/AIDS and/or TB/STD training were reviewed on March 27, 2013. The facility failed to ensure that employees # 6 and 7 received a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum.Employee # 6 was hired by the facility as a counselor on July 11, 2011, and was required to 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 by July 11, 2012. However, the record did not include documentation of either training as of the date of inspection.Employee # 7 was hired by the facility as a counselor on July 6, 2011, and was required to receive at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training by July 6, 2012. However, the record did not include documentation of TB/STD training as of the date of inspection.The findings were confirmed by the project's Assistant CEO during the record review.
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Plan of Correction
Employees 6 and 7 in fact did not attend the required trainings within their first year of hiring. These include HIV/AIDS and TB/STD for employee #6. These trainings have been scheduled and employee #6 will attend both within the next several months.
Employee #7 is scheduled to attend 4 hours of TB/STD Training in May of 2013. These will fulfill the requirements for both employee #6 and #7. The Treatment Supervisor will assume the role of auditing employee's training manuals. These manuals will be audited once every 2 months. Therefore, training manuals will have been inspected 6 times annually. This will ensure that all employees have attended not only the necessary trainings but also trainings required for new employees. |
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.
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Observations
Based upon the review of the facility's weekly staffing schedules and staff member's CPR certifications, the facility failed to ensure that at least one person trained in these skills was onsite during all of the facility's hours of operation.The findings include:The facility's weekly staffing schedules and staff member's CPR certifications were reviewed on March 28, 2013. The facility is open for services Monday through Friday, from 8:30 AM to 9:00 PM. The facility failed to ensure that at least one person certified in CPR was onsite on the following dates and at the corresponding times:February 27 and 28, 2013, from 8:00 PM to 9:00 PM.March 5, 6, 7, 12, 13, 14, 19, 20 and 21, 2013, from 8:00 PM to 9:00 PM.Employee #5 lacked CPR certification and was the only staff person working from 8:00 PM - 9:00 PM on the above mentioned dates. Employee #5 did complete CPR certification on March 22, 2013.The Assistant CEO confirmed the findings during the exit interview.
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Plan of Correction
The entire clinical staff was trained/certified in CPR on March 22, 2013. Employee #5 is now certified in CPR and coverage does now exist throughout all hours of operation. These hours are still 8:30am-9pm. Therefore, a staff member certified is present through all hours of operation. The Assistant CEO will ensure that CPR coverage is present throughout all hours of operation. Schedules will be checked daily by the Assistant CEO. Treatment Supervisor will assume this duty in absence of the Assistant CEO. This allows the Assistant CEO/Treatment Supervisor to verify that CPR certification is present during all hours of operation. In addition, WVADS, Inc. will make it necessary for all clinical staff to be certified in CPR. Therefore, there will be no gap in coverage. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based upon the physical plant inspection, the facility failed to maintain a minimum of one operable automatic smoke detector on one of two floors.The findings include:The physical plant inspection was conducted on March 28, 2013, from approximately 8:30 AM to 9:00 AM. The facility failed to maintain an automatic smoke detector on the first floor of the facility.The Assistant CEO and the Clinical Supervisor accompanied the Licensing Specialist during the inspection and confirmed the findings.
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Plan of Correction
Two smoke detectors have been placed on the 1st floor where they did not exist during the inspection. One has been placed in the rear of the building while the other has been placed in the waiting room. Therefore, smoke detectors exist on all floors of the building. The Assistant CEO will ensure that a smoke detector is set off during monthly fire drills. The Assistant CEO will also check the batteries on each smoke detector monthly (not on same day as fire drill-therefore batteries will be checked twice each month). The results of the tests will be written on the monthly fire drill log. |
705.28 (d) (7) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(7) Set off a fire alarm or smoke detector during each fire drill.
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Observations
Based upon a review of the facility's fire drill log and an interview with the Assistant CEO, the facility failed to set off a fire alarm or smoke detector during twelve of twelve monthly fire drills.The findings include:The facility's fire drill log was reviewed on March 28, 2013. The fire drill log contained documentation of twelve monthly fire drills that were conducted from March 2012 to February 2013.The Licensing Specialist met with the Assistant CEO to review the facility's fire drill practices. The Assistant CEO stated that the facility did not set off the fire alarm system or a smoke detector during fire drills conducted during the months of: March 2012; April 2012; May 2012; June 2012; July 2012; August 2012; September 2012; October 2012; November 2012; December 2012; January 2013; and February 2013.The findings were re-confirmed by the Assistant CEO during the exit interview.
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Plan of Correction
As stated, WVADS, Inc. does hold monthly firedrills. However, neither the fire alarm or smoke detectors were ever set off during the drills. From here on in, the smoke detectors will be set off during monthly firedrills. This will be done by a member of the administration team. This will ensure that the firedrill requirements are being handled in regards to the regulations required. |
709.82(d)(1) LICENSURE Treatment and rehabilitation services
709.82. Treatment and rehabilitation services.
(d) Counseling shall be provided to a client on a regular and scheduled basis. The following services shall be included and documented:
(1) Individual counseling, at least twice weekly.
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Observations
Based upon the review of client records, the facility failed to document that individual counseling was provided at least twice weekly in three of five records. The findings include:Treatment services are available Monday through Friday each week and are offered in three, four-hour time slots: morning, afternoon and/or evening hours. Five client records requiring documentation of individual counseling sessions were reviewed on March 28, 2013. The facility failed to document that individual counseling sessions were being provided twice weekly in records # 3, 10 and 11.Client # 3 was admitted on September 4, 2012, and transferred to another level of care on October 11, 2012. The facility was required to provide two counseling sessions per week from September 4, 2012 to October 11, 2012. However, as per documentation contained in the record, the facility only provided individual counseling sessions on the following dates: September 13, 2012; September 20, 2012; October 4, 2012; and, October 11, 2012.Client # 10 was admitted on April 10, 2012, and transferred to another level of care on May 30, 2012. The facility was required to provide two counseling sessions per week from April 10, 2012 to May 30, 2012. However, as per documentation contained in the record, the facility only provided individual counseling on the following date: April 19, 2012.Client # 11 was admitted on July 31, 2012, and transferred to another level of care on September 6, 2012. The facility was required to provide two counseling sessions per week from July 31, 2012 to September 6, 2012. However, as per documentation contained in the record, the facility only provided individual counseling sessions on the following dates: August 14, 2012; August 21, 2012; and, September 4, 2012.The findings were confirmed by the Assistant CEO during the record review.
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Plan of Correction
The administrative team has met in regards to this specific issue. It was determined that each counselor will have certain hours of their shifts blocked off specifically for clients involved in the Partial Hospitalization Program. This will ensure that each client is seen at least twice weekly for a minimum of one half hour as required per licensing standards. All counselors will be required to take part in this specific corrective action plan. For the next 4 months, the Treatment Supervisor will conduct bi-weekly chart audits on each clinician. This will ensure clients are being seen at least two times a week. After 4 months, the Treatment Supervisor may randomly request charts from any clinician to ensure individuals are being seen two times weekly. If necessary, the Assistant CEO will assume these duties if Treatment Supervisor is not available. |