INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 29-30, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Stairways Behavioral Health 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)(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 on a review of staff schedules and CPR certifications, the facility failed to provide a sufficient number of staff persons trained in CPR during the project's hours of operation.
The findings include:
The staff schedules and staff CPR certifications were reviewed on May 29-30, 2013. The staff schedules were reviewed for the time frame of May, 2013. The facility is a 24 hour inpatient facility. Based on the staff schedules and the CPR certifications provided by the facility, the facility failed to ensure that at least one person, certified in CPR, was onsite during the project's hours of operation from 11 PM to 7 AM on May 1-29, 2013. The only staff member working the 11 PM to 7 AM shift on May 4, 5, 6, 11, 12,13,14, 20, 21, 25, 26, and 27, 2013 was not certified in CPR.
The Facility Director was interviewed on May 30, 2013 and confirmed the findings.
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Plan of Correction
The 11:00pm-7:00am staff member that was not certified completed the training in CPR and first aid on 6/7/13. All staff will be required to keep up to date CPR and First aid certification. All new staff hired will be required to obtain this certification within 30 days of hire. Program Director will monitor all staff certification and will not schedule those that are not certified to work alone.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training in one of two personnel records.
The findings include:
Seven personnel records were reviewed on May 29-30, 2013. Two personnel record required the completion of 12 clock hours of annual training. One personnel record pertained to the project director. The facility training year is January-December. The 2012 training year was reviewed. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since February 2006. There were 0 hours of training documented for the 2012 training year.
The Facility Director was interviewed on May 30, 2013 and confirmed the findings.
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Plan of Correction
Facility Director met with the Project Director on 6/10/13 to review this finding. The Project Directors training plan will be included in the programs quarterly staff training plan review conducted the Facility Director. The Facility Director will schedule a meetings quarterly to review the findings with staff not in compliance. A plan will be developed with the staff member to insure compliance effective July 1, 2013.
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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, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel record.
The findings include:
Seven personnel records were reviewed on May 29-30, 2013. Two personnel records pertained to counselors. One personnel record required the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel record # 4.
Employee # 4 was hired on January 5, 1998. The facility training year is from January through December. The 2012 training year was reviewed. There were 14 clock hours of annual training documented for the 2012 training year.
The Facility Director was interviewed on May 30, 2013 and confirmed the findings.
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Plan of Correction
Project Director will review all training plans quarterly for compliance. Program Manager will work with staff in monthly supervision to identify training needs and insure that training needs and requirements are being met effect 6/10/13. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in three of three personnel records.
The findings include:
Six personnel records were reviewed on May 29-30, 2013. Three personnel records reviewed were new hires and required documentation that the staff were instructed in the use of the fire extinguisher upon staff employment. The facility did not document that staff members were instructed in the use of the fire extinguisher upon staff employment in personnel records # 3, 6 and 7.
Employee # 3 was hired on March 11, 2013. Fire extinguisher training was due to be completed no later than March 18, 2013 . The facility did not document the completion of fire extinguisher training until April 1, 2013.
Employee # 6 was hired on January 8, 2013. Fire extinguisher training was due to be completed no later than January 15, 2013 . The facility did not document the completion of fire extinguisher training until February 20, 2013.
Employee # 7 was hired on November 5, 2012. Fire extinguisher training was due to be completed no later than November 12, 2012 . The facility did not document the completion of fire extinguisher training until February 6, 2013.
The Facility Director was interviewed on May 30, 2013 and confirmed the findings.
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Plan of Correction
Employee #3,6 and 7 have completed fire extinguisher training effective 6/7/13.
Program Director has developed a new employee check list in order to insure that all required trainings for new hires are completed. Program Manager will review this with every new hire effective 6/14/13.
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on a review of facility documentation, the facility failed to document an annual report for the fiscal year of July 1, 2011 to June 30, 2012.
The findings included:
During the onsite inspection on May 29-30, 2013, the annual report for the fiscal year July 1, 2011 to June 30, 2012 was requested for review. There was no documentation of an annual report.
The Facility Director was interviewed on May 30, 2013 and confirmed the findings.
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Plan of Correction
The Chief Compliance Officer will make available the board approved Annual Report to the public each year by posting the report in the local newspaper for public notice by December of each year. Program Director will be responsible for insuring this occurs and receives a copy of the notice posting by the compliance department each December effective 12/31/13. |
709.30 LICENSURE Client Rights
709.30. Client rights.
The project director shall develop written policies and procedures on client rights and shall demonstrate efforts toward informing clients of the following:
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Observations
Based on a review of client records, the client handbook, and a physical plant inspection, the facility failed to provide documentation that clients were informed of their right to appeal a decision limiting access to their records to the project director in three of three client records.
The findings include:
Six client records were reviewed on May 29-30, 2013. Three client records reviewed required documentation that the client was informed of their rights. There was no documentation that the client was informed of the right to appeal a decision limiting access to their records to the project director in client records # 1, 2 and 3.
The Facility Director was interviewed on May 30, 2013 and confirmed the findings.
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Plan of Correction
Program Director will update the client right form/signature sheet in the intake packet to include; "the right to appeal a decision limiting access to their records to the project director" effective July 1, 2013. Program manager will inform program staff on 6/19/13 in a staff meeting of the update and monitor the charts for the next 30 days or until August 1,2013 to insure compliance. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to document physical examinations during the intake procedure in two of four client records.
The findings include:
Six client records were reviewed on May 29-30, 2013. Four client records required documentation of a physical examination during the intake procedure. The facility did not document a physical examination during the intake procedure in client records # 1 and 5.
Client # 1 was admitted on May 13, 2013. The physical examination was to be completed by May 20, 2013. The physical examination was completed on May 23, 2013.
Client # 5 was admitted on January 10, 2013. The physical examination was to be completed by January 17, 2013. The physical examination was completed on January 30, 2013.
The Facility Director was interviewed on May 30, 2013 and confirmed the findings.
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Plan of Correction
The program manager has developed a admit check that has been implemented into the intake process identifying scheduling and documenting completion of the physical examination within seven days of the admission for monitoring purposes. The program manager will monitor compliance of this regulation with in her monthly random chart audits effective 7/1/2013. |
709.53(a)(9) LICENSURE Aftercare plans
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(9) Aftercare plan, if applicable.
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Observations
Based on the review of client records, the facility failed to document an aftercare plan in one of two client records.
The findings include:
Six client records were reviewed on May 29-30, 2013. Three client records were reviewed as discharged clients. Two client records required documentation of an aftercare plan. The facility did not document an aftercare plan in client record # 4.
Client # 4, admitted on March 15, 2013 and successfully discharged on April 25, 2013, required an aftercare plan. There was no documentation of an aftercare plan.
The Facility Director was interviewed on May 30, 2013 and confirmed the findings.
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Plan of Correction
Program manager met with the clinical staff on 6/12/13 and reviewed the regulation and program process for completing aftercare plans. Program manager will monitor compliance with this regulation monthly through chart audits effective 7/1/2013 and review deficiencies with staff in monthly supervisions. |
709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on the review of client records, the facility failed to document follow-up information in two of three client records.
The findings include:
Six client records were reviewed on May 29-30, 2013. Three client records were reviewed as discharged clients and required documentation of follow up information. Per agency policy, follow up is to be completed within 7 days of discharge. The facility did not document follow up information per agency policy in client records # 4 and 5.
Client # 4 was admitted on March 15, 2013 and discharged on April 25, 2013. Follow up information was to be completed by May 2, 2013. There was no documentation of follow up information.
Client # 5 was admitted on January 10, 2013 and discharged on January 31, 2013. Follow up information was to be completed by February 7, 2013. There was no documentation of follow up information.
The Facility Director was interviewed on May 30, 2013 and confirmed the findings.
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Plan of Correction
Program manager met with the clinical staff on 6/12/13 and review the regulation. A discharge check list will be used to monitor compliance with this regulation. Program manager will monitor compliance with this regulation through monthly chart audits effective 7/1/2013 |