INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 14-15, 2015 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Parkside Recovery 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 and training records, the facility failed to provide documentation of HIV/AIDS and TB/STD training in two of thirteen personnel records reviewed
The findings include:
Thirteen personnel records which required documentation of mandatory communicable disease training were reviewed on October 14-15, 2015. The facility failed to provide documentation of HIV/AIDS and TB/STD training for employees12 and 13.
Employee #12 was hired on May 20, 2013 as a counselor. The employee was required to obtain a minimum of 6 hours of HIV/AIDS training prior to May 20, 2014. The facility failed to provide documentation of HIV/AIDS training for employee #12 as of the date of the inspection.
Employee #13 was hired July 17, 2013 as a security guard. The employee was required to obtain at least 4 hours of TB/STD training prior to July 17, 2015. The facility failed to provide documentation of TB/STD training for employee #13 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
Employee #12 received HIV/AIDS training on October 22, 2015. Employee #13 is scheduled to receive TB/STD training on November 20, 2015. The Training Supervisor will be responsible for achieving and maintaining compliance with the standard. The specific course of action with be a monthly meeting between the Training Supervisor and the Program Director to go over all employees currently hired and new hire employees in the LMS training system to assure all trainings have been scheduled and attended as required to assure this deficiency does not re-occur. |
705.22 (2) LICENSURE Building exterior and grounds.
705.22. Building exterior and grounds.
The nonresidential facility shall:
(2) Keep the grounds of the facility clean, safe, sanitary and in good repair at all times for the safety and well being of clients, employees and visitors. The exterior of the building and the building grounds or yard shall be free of hazards.
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Observations
Based upon a physical plant inspection, the facility failed to keep the facility safe, sanitary, and in good repair at all times for the safety and well being of clients, employees and visitors.
The findings include:
The physical plant inspection occurred on October 15, 2015 at approximately 9:30 am. During the physical plant inspection, the licensing specialist observed a 2' x 2' hole in the ceiling of the downstairs female staff restroom.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The damanged ceiling in the downstairs female staff restroom is scheduled for repair on November 13, 2015. The Facility Supervisor will be responsible for achieving and maintaining compliance with the standard. The Facility Supervisor will walk throughout the building, inspect each room and log his results weekly to ensure this deficiency does not re-occur. |
709.26(c) LICENSURE Personnel Management
709.26. Personnel management.
(c) The project director shall develop written policies and procedures to provide for ongoing staff training and staff evaluation. Documentation shall include, but is not limited to:
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Observations
Based on the review of client records, the facility failed to ensure that an informed and voluntary consent to release information included a dated signature of witness in one of twenty client records reviewed.
The findings included:
Twenty patient records requiring complete informed and voluntary consent to release information forms were reviewed on October 14-15, 2015. The facility failed to ensure that the dated signature of a witness was on the consent to release information forms in client record #2.
Client # 2 was admitted into treatment on October 26, 2004 and was still an active client at the time of the inspection. Four separate release of information forms were signed and dated on 04/28/15/ - one to a goverment agency, one to the urinalysis lab, one to the emergency contact, and one to the funding source; however; all four release of information forms did not include the dated signature of witness.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
A staff training was held on November 4th, 2015 on how to properly and completely fill out a client consent to release information. The training will stress the importance of the dated and signature of the witness. The Clinical Supervisors will conduct the training and will be responsible to ensure compliance with this standard. The Clinical Supervisors will ensure compliance by conducting weekly audits of client files in their supervision sessions with counselors to ensure this deficiency does not re-occur. Client #2 noted in the POC was discharged before dated witness signature on new releases could be completed |