INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on July 7, 2017 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment, Program Licensure Division. Based on the findings of the on-site inspection, Resources for Human Development 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:
|
Plan of Correction
|
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
|
Observations
Based on a review of personnel records, the facility failed to ensure that the counselor assistant personnel record contained documentation of a semiannual written individual performance evaluation for employee # 8, who was hired as a counselor assistant on 11/1/16 and was still in the position at the time of the inspection.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Unit Director reviewed the personnel record following the exit interview. Unit Director met with Counselor Assistant 7/21/17 to complete the Semiannual Performance Review. The review has been placed in the personnel file. The Unit Director and Counselor Assistant reviewed supervision guidelines and requirements within the first 12 months of the Counselor Assistant assuming a caseload. The Unit Director and Assistant Director also reviewed supervision guidelines for a Counselor Assistant to ensure all requirements are met with future Counselor Assistants employed at the treatment program. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
|
Observations
Based on a review of 8 personnel records, the records for 2 employees did not contain any documentation of fire extinguisher/fire safety training completed upon employment. Additionally, the facility failed to complete fire extinguisher/fire safety training within a reasonable timeframe for 4 employees.
Employee #2 was hired as the facility director on 9/26/16 and was still in that position at the time of inspection. The fire extinguisher/fire safety training was not completed until 7/6/17.
Employee #3 was hired as the clinical supervisor on 1/15/17 and was still in that position at the time of inspection. The fire extinguisher/fire safety training was not completed until 7/6/17.
Employee # 4 was hired as a counselor on 1/15/17 and was still in that position at the time of inspection. The fire extinguisher/fire safety training was not completed until 7/6/17.
Employee # 5 was hired as a counselor on 5/10/17 and was still in that position at the time of inspection. There was no documentation of a completed fire extinguisher/fire safety training in the record.
Employee #6 was hired as a counselor on 12/21/16 and was still in that position at the time of inspection. The fire extinguisher/fire safety training was not completed until 7/6/17.
Employee # 8 was hired as a counselor assistant on 11/1/16 and was still in that position at the time of inspection. There was no documentation of a completed fire extinguisher/fire safety training in the record.
These findings were reviewed with facility staff during the licensing process.
|
Plan of Correction
Employee #5 & Employee # 8 completed the Fire Extinguisher/Fire Safety training on Tuesday July 11, 2017 with the Unit Director and completed documentation confirming training was completed.
The Unit Director and Assistant Director will include Fire Extinguisher/Fire Saftey training for all hired staff within the first 10 days of employment. |
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
A review of the July 2016 through June 2017 fire drill logs was conducted during the licensing process. The facility failed to conduct unannounced drills during the months of September 2016, February 2017 and April 2017.
These findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
Effective June 1, 2017 the Unit Director has scheduled 1 unannounced fire drill per month through December 31, 2017. The Assistant Director is aware of the scheduled fire drills assist Unit Director in accurate, monthly execution of drills. |
709.34 (c) (2) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(2) Death or serious injury due to trauma, suicide, medication error or unusual circumstances.
|
Observations
Based on the review of the facility's unusual incident reports, it was discovered that the facility failed to notify the Department within 3 days following an unusual incident, which involved the offsite death of a client, that occurred on June 20, 2017.
These findings were reviewed with project and facility staff during the licensing process.
|
Plan of Correction
An all staff meeting was held on July 14, 2017. The Unit Director and Assistant Director educated and trained all staff the proper procedure for reporting unusual incidents to the state Department of Drug and Alcohol Programs within 72 hours of the incident. This will be reinforced at future all staff meetings.
Additionally, in future instances of an unusual incident the staff persons involved will immediately inform the Unit Director and/or Assistant Director. The Unit Director and/or Assistant Director will work with the staff members involved to ensure all documentation is completed accurately and within the time frame for submission. |