INITIAL COMMENTS
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Based on the concerns arising from COVID-19, The Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, has implemented temporary procedures for conducting an annual renewal inspection.
The inspection will be divided into two parts.
1, an abbreviated off-site inspection, will be conducted off site, and will require the submission of administrative information via email to a Licensing Specialist.
2, an abbreviated on-site inspection, will be conducted on-site, at a later date and will include a review of client/patient records, and a physical plant inspection.
This report is a result of Part 1, an abbreviated off-site inspection, conducted on August 19, 2020 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Not all regulations were reviewed, the remainder of the regulations, not reviewed during Part 1, will be reviewed at a later date.
Based on the findings of Part 1, an abbreviated off-site inspection, Kensington Hospital Outpatient Treatment Program, 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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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on an administrative review of the facility's Staffing Requirement Facility Summary Report (SRFSR) form, the facility failed to ensure that a full-time clinical supervisor was employed for every eight full-time counselors. The facility's counselor Full Time Equivalent (FTE) equated to 9.4 counselors. The FTE calculation for the number of clinical supervisors needed is as follows:
The total # of hours project-wide devoted to D&A clients divided by the project's standard workweek, or 353.5 hours / 37.5 hours = 9.4 FTE
Based on the calculation, the project is required to have at least one full-time clinical supervisor on staff and based on the facility-submitted SRFSR, the facility does not employ a full-time clinical supervisor.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Hospital's current Program Director has now also been assigned the responsibilities of the Facility Director of the Inpatient Program effective 9/20/2020.
Kensington Hospital also has a full-time Clinical Supervisor employed and on staff in order to meet the Staffing Requirements.
The Project will continued to maintain a full-time Clinical Supervisor for every eight full-time counselors.
The Executive Assistant will be responsible for completing all future DDAP inspection Staffing Requirement forms and have the CEO review the forms prior to submission to DDAP to assure the proper completion of the positions.
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704.11(a)(2) LICENSURE Overall Training plan
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:
(2) An overall plan for addressing these needs.
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Observations
Based on a review of the facility's comprehensive staff development program, the facility failed to document an overall plan for addressing the staff training needs for the 2020 training year.
The findings were reviewed with facility staff during the licensing inspection process.
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Plan of Correction
A comprehensive Overall Training Plan has since been developed by the Hospital's Employee Educator on 8/26/2020. The Overall Training Plan now addresses the Agency staff's training needs for the 2020 Training Year. The Overall Training Plan includes:
New Hire Training (for all employees, including Department specific Policies & Procedures,
New Hire Training (for the Nursing Staff)
Annual Mandatory Training (for all employees including updates/revision to any Department specific Policies & Procedures
On-going Performance Improvement Education and Re-Education.
The Overall Training Plan will now be used by the Employee Educator for all new hires, mandated annual trainings, as well as, on-going Performance Improvement Education and re-education.
In order to assure continued compliance of a comprehensive Overall Training Plan, the Overall Training Plan will be reviewed by the Hospital's Employee Educator on a yearly basis by 1/31 of the new year.
The Executive Assistant will have the responsibility to assure the Overall Training Plan has been updated/revised each year by 1/31 of that year.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of personnel records, the facility failed to document an annual written individual training plan, with input from both the employee and the supervisor in one of four personnel records reviewed.
Employee #1 was hired on November 8, 2016 and was still employed at the time of the inspection. A training plan for this employee was completed on January 23, 2020; however, there was no documentation that this training plan was developed with input from both the employee and supervisor as plan was only signed by the employee.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Employee #1's Training Plan was developed with input from both the employee and supervisor, however, supervisor was off-site of the time of the development of the Training Plan and did not sign the Training Plan. On 8/20/2020, the Training Plan was forwarded and signed by
Employee #1's Supervisor.
In order to assure continued compliance, the Executive Assistant will be responsible to assure that the Training Plans submitted for the new Training Year (by 1/31) are complete with Employee's Signature and Date and the Supervisor's Signature and Date before they are filed. |
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 all staff persons received the minimum of six hours of HIV/AIDS training and at least four hours of TB/STD and other health related topics within the regulatory timeframe in one of four personnel records reviewed.
Employee #4 was hired as a counselor on August 27, 2018 and was due to have the communicable disease trainings no later than August 27, 2019. Employee #4 completed the HIV/AIDS training on November 23, 2019 and there was no documentation in the personnel file of the completion the TB/STD 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
Kensington Hospital's Employee Educator will now be responsible for providing the required training to counseling staff needing the required six hours HIV/AIDS training and four hours of TB/STD, as well as, other health related topics within the regulatory timeframe.
In order to assure continued compliance, the counseling staff's training will be monitored by the Clinical Supervisor at time of monthly Supervisor to assure the required trainings are obtained within the regulatory timeframe. |
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 personnel records and the facility's Staffing Requirement Facility Summary Report (SRFSR), the facility failed to ensure that all counselors completed at least 25 clock hours of training annually in one of two applicable personnel records reviewed.
Employee #3 was hired on September 27, 2015 and was still employed at the time of the inspection. The employee had 12.75 clock hours of training documented for the 2019 training year.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Clinical Supervisor met with this particular counselor on 8/19/2020 regarding the requirement of completing 25 total training hours for the Training year 2019.
In order to assure all counselors meet their required annual training hours, the Clinical Supervisor is responsible to monitor the counselors' total training hours at time of their monthly Supervision meetings. This way, the total number of training hours are monitored by both the employee and Clinical Supervisor to assure the completion of 25 hours is met by the required timeframe. |
705.10 (d) (4) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on an administrative review of the November 2019 through July 2020 fire drill logs, the facility failed to include the exit route used on every fire drill log conducted.
These findings were reviewed with facility staff during the licensing process
This is a repeat citation from the October 31, 2019 licensing inspection.
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Plan of Correction
The Fire Drill log form has been revised to include the exit route used by staff. The form was revised on 8/20/2020 by the Executive Assistant and was forwarded to the Hospital's Fire Drill representative for use on 8/20/2020.
In order to assure continued compliance, the Safety Officer will monitor the submitted fire drill logs on a monthly basis to assure they are completed on the revised form (which now includes the exit route used by staff). This review will be reported to the Safety Committee on a bi-weekly basis for the next six (6) months to assure continued compliance. |