INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 17-18, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, McP/Caring Together 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 and a plan of correction is due on April 19, 2011.
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Plan of Correction
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704.11(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on the review of personnel records and an interview with the facility director, the facility failed to document staff feedback on completed training in three of three personnel records.
The findings include:
On March 17, 2011, three personnel records were reviewed for documentation of staff feedback on completed training. The facility did not document staff feedback on completed training, as per facility policy in personnel records # 1, 2 and 3.
The Facility ' s policy titled " The collection of feedback on completed training " states:
" Staff who attends a training, seminar, etc., will be expected to complete an evaluation form which will state the program ' s educational objectives, rating of the program, and will include a suggestion and comment section. If available, staff can bring back a photocopy of the original evaluation form from the conference. Otherwise, staff will be asked to complete Caring Together ' s Evaluation Form (See Training Evaluation Form) upon their return. Completed forms will be kept in the individual staff files. "
Personnel records #1, 2, and 3, did not contain training feedback forms for the training completed during the 2009-2010 training year.
An interview with the facility director on March 17, 2011 confirmed that personnel records #1, 2, and 3, did not contain training feedback forms for training completed during the 2009-2010 training year.
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Plan of Correction
Program Manager will institute requirement that training feedback forms are to be completed within 7 days of training. PM will automatically email copy of training feedback form to staff after each training attended as prompt. |
711.94(b) LICENSURE Display Hours of Operation
711.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on a physical plant inspection and an interview with the facility director, the facility failed to display the hours of operation conspicuously to the general public.
The findings include:
A physical plant inspection was conducted on March 17, 2011 at approximately 1:00 PM. The facility was required to display the hours of operation to the general public, but at the time of inspection the hours of operation were not displayed.
An interview with the facility director on March 17, 2011 confirmed that the hours of operation were not displayed to the general public.
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Plan of Correction
PM will replace paper sign (which had fallen) with more permanent and secure sign stating hours of program. |
711.94(c) LICENSURE Display Emerg. Telephone Number
711.94. 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 a physical plant inspection and an interview with the facility director, the facility failed to display a telephone number conspicuously to the general public.
The findings include:
A physical plant inspection was conducted on March 17, 2011 at approximately 1:00 PM. The facility was required to display a telephone number to the general public, but at the time of inspection a telephone number was not displayed.
An interview with the facility director on March 17, 2011 confirmed that a telephone number was not displayed to the general public.
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Plan of Correction
PM will replace paper sign (which had fallen) with more permanent and secure sign stating telephone number of program. |
711.96(b) LICENSURE Appeal of Termination
711.96. Notification of termination.
(b) The client shall have the opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to inform a client of her right to request reconsideration of the decision to terminate her treatment in one of one records.
The findings include:
On March 18, 2011, one involuntarily terminated client's record was reviewed for documentation of the client being given the opportunity for reconsideration of the facility's decision to terminate her treatment. The facility failed to inform the client of her right to request reconsideration of the facility's decision to terminate her treatment, as per facility policy, in client record #5.
The facility ' s policy titled " Involuntary discharge/termination criteria " states:
" The Facility Director, Program Director, or Primary Addictions Counselor of the Caring Together Program shall inform the client in writing of the decision to terminate, the reason for termination, and that the client can appeal the decision to terminate. A copy of this shall be maintained in the client ' s chart. Each client has to right to appeal the discharge or termination and should do so in writing to the Program Director. "
The termination letter in client record #5 dated 2/1/11 informed the client of the reason for her termination, but the letter did not inform the client of her right to appeal the decision to terminate her treatment.
An interview with the facility director on March 18, 2011 confirmed that the termination letter in client record #5 did not inform the client of her right to request reconsideration of the decision to terminate her treatment.
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Plan of Correction
PM will review relevant policy prior to each client termination to ensure compliance. |