INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 18, 2012 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.
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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 a minimum of 6 hours of HIV/AIDS and/or at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training in one of seven personnel records.
The findings include:
Seven personnel records were reviewed on December 10 through 12, 2012. Seven personnel records required documentation of HIV/AIDS and/or tuberculosis, sexually transmitted diseases and other health related topics training. Employee record # 4 did not include documentation of the completion of the required training.
Employee # 4 was hired on February 11, 2011. HIV/AIDS training was due to be completed by February 11, 2012. There was no documentation that the employee had completed the HIV/AIDS training as of December 12, 2012.
An interview with the project director on December 12, 2012 confirmed the findings.
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Plan of Correction
Employee # 4 is scheduled for HIV/AIDS training on 3/22/2013 and will be in compliance with the training standard. Furthermore all employees who do not currently have the training are also scheduled for the training on 3/22/2013.
In addition the Program Director and Supervisory staff will meet quarterly to review all training files to assure all staff members meet the required standards.The program Director will review individually with staff on a quarterly basis the number of hours they still need to meet the standard. The Program Director will be responsible to assure that there are no training defiecencies going forward. |
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 three of three personnel records.
The findings include:
Seven personnel records were reviewed on December 10 through 12, 2012. Three personnel records pertained to counselors. Three personnel records were required to include documentation of the completion of 25 clock hours of annual training. The facility's training year is from July through June. The facility's 2011/2012 training year was reviewed. The facility failed to document 25 clock hours of annual training in personnel records # 4 and 6.
Employee # 4 was hired on February 21, 2011. Employee # 4 had only 4 clock hours of training documented for the 2011/2012 training year.
Employee # 6 was hired on May 18, 2009. Employee # 6 had only 18 clock hours of training documented for the 2011/2012 training year.
An interview with the project director on December 18, 2012 confirmed the findings.
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Plan of Correction
Plan of Correction: The program Director and Clinical Supervisor met with both employee # 4 and employee # 6 to review the training requirements for counselors. The training requirements were reviewed with all staff members at a staff meeting on 1/4/2013 and all staff were informed of their responsibility to maintain the training standards as part of their employment. In addition the Program Director and Supervisory staff will meet quarterly to review all training files to assure all staff members meet the required standards. Completion Date: 1/4/2013
Status:
No POC
Date:
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on a physical plant tour, the facility failed to ensure that all fire extinguishers are inspected and approved annually.
The findings:
The physical plant tour took place on December 18, 2012 at 5 pm. During the tour of the nurses' station it was observed that the fire extinguisher in the medication room was last inspected on July 2011. An interview with the project director and facility director on December 18, 2012 confirmed the findings.
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Plan of Correction
Plan of Correction: the fire extinguisher in the medication area has been replaced and is currently operable. Going forward the Program Director will tour the facility with personnel from facilities department to assure all fire extinguishers are within code and operable. |
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.
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Observations
Based on a review of employee training records, the facility failed to ensure that each employee received the required training in the use of a fire extinguisher upon employment.
The findings included:
Seven personnel records were reviewed on December 10 through 12, 2012. Each was required to have documentation of fire extinguisher training. One of seven records failed to document that the employee had received fire extinguisher training.
Employee #7 was hired on September 27, 2012 . The training record was reviewed and no documentation was recorded to indicate that the employee had ever received fire extinguisher training.
An interview with the project director on December 18, 2012 confirmed the findings.
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Plan of Correction
Plan of Correction: Employee will be re-trained on fire safety and all supporting documentation will be recorded in employee personnel record. All employees will be trained by 2/1/2013.In addition the Program Director and Supervisory staff will meet quarterly to review all training files to assure all staff members meet the required standards.Program Director will meet with individual staff after each quarterly meeting to update them on the status of their training hours and what is still needed to meet the requirement. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of employee training records, the facility failed to ensure that each employee received the required training for emergencies.
The findings included:
Seven personnel records were reviewed on December 10 through 12, 2012. Each was required to have documentation of emergency training. One of seven records failed to document that the employee had received emergency training.
Employee #7 was hired on September 27, 2012. The training record was reviewed and no documentation was recorded to indicate that the employee had ever received emergency training.
An interview with the project director on December 18, 2012 confirmed the findings.
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Plan of Correction
Plan of Correction: Employee will be re-trained on emergencies and all supporting documentation will be recorded in employee personnel record. All staff will be trained by 2/1/2013.
In addition the Program Director and Supervisory staff will meet quarterly to review all training files to assure all staff members meet the required training standards. The Program Director will meet with individual staff after the quarterly meetings with supervisory staff to update them on what indivduals need to comply with the training standards. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of administrative policies and Board meeting minutes the project failed to demonstrate that the project director assisted the governing body in formulating project goals and objectives for the 2012/2013 fiscal year.
The findings were:
A review of administrative documentation and conversation with the project director on December 10, 2012 confirmed that the project director did not assist nor present to the governing body the project goals and objectives for the fiscal year of July 1, 2012 to June 30, 2013.
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Plan of Correction
Effective December 11, 2012 the Project Director assisted the governing body in formulating project goals and objectives for the 2012/2013 fiscal year. This will be maintained with an annual review in the 3rd Quarter Board Meeting of each fiscal year.I was going to put a corrective action date as directed by Irene Sweets but the system would not allow me to do so stating the corrective action date of 12/11/2012 was before the survey was conducted. I used 12/18/2012 as the date so the system would accept it. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in one of one client records.
The findings include:
Thirteen client records were reviewed on December 18, 2012. Four of the client records reviewed were those of discharged clients. One of the discharged clients was involuntarily terminated from treatment at the project. The facility failed to notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project, in client record # 13.
Client # 13 was admitted into treatment on April 11, 2012 and was involuntarily terminated from the project on October 5, 2012. There was no documentation of written notification provided to the client as of the on-site inspection which was conducted on December 18, 2012.
An interview with the project director, facility director and clinical supervisor on December 18, 2012 confirmed the findings.
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Plan of Correction
It is NHS policy to provide all clients being involuntarily discharged from the program a letter of termination stating the reason for discharge. The individual would have 48 hours to write an appeal. However, in the case of an individual threatening or committing physical violence toward staff or clients that individual would be escorted from the building immediately and forbidden to return to the program. The individual would be told verbally they are receiving a "notice of termination" from the program and they have a right to appeal. The notice would be mailed the day the client was informed and escorted from the building. The clinical supervisor is responsible to assure this defiicency has been corrected. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to provide a psychosocial evaluation to include assets/strengths, support systems, coping mechanisms and negative factors that may inhibit treatment of the client in seven of thirteen client records.
The findings include:
Thirteen client records were reviewed on December 18, 2012. All records were reviewed for psychosocial evaluations.
The psychosocial evaluations in client records #1, 8 and 10 did not include an evaluation of the client's problems/needs and how they would impact treatment.
The psychosocial evaluations in client records #1, 8, 9, 10, 11, 12 and 13 did not include an evaluation of the client's assets/strengths and how they would impact treatment.
The psychosocial evaluations in client records #1, 8, 9, 10, 11, 12 and 13 did not include an evaluation of the client's support systems and how they would relate to treatment.
The psychosocial evaluations in client records #1, 8, 9, 10, 11, 12 and 13 did not include an evaluation of the client's coping mechanisms and how they would relate to or impact treatment.
The psychosocial evaluations in client records #1, 8, 9, 10, 11 and 12 did not include an evaluation of the client's negative factors and how they would impact treatment.
The psychosocial evaluations in client records #1, 8, 9, 10, 11, 12 and 13 did not include an evaluation of the counselor conclusions/impressions of the client.
An interview with the project director, facility director and clinical supervisor on December 18, 2012 confirmed the findings.
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Plan of Correction
Plan of Correction: Program Director and Clinical Supervisor will conduct training for all clinical staff on the proper procedure for completing the psychosocial evaluation. The training will be conducted on 1/18/2013. In addition, the focus of individual supervision will be on psychosocial evaluations. The Program Director will also focus on the psychosocial evaluations in monthly chart audits. The program will also enlist the support of the NHS Quality Improvement Department to add emphasis on psychosocial evaluations when conducting required monthly chart audits. |
709.94(b) LICENSURE Project management services
709.94. 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, the facility failed to display the facility's hours of operation that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on December 18, 2012. The facility's hours of operation that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display their hours of operation. An interview with the project director and facility director on December 18, 2012 confirmed the findings.
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Plan of Correction
Plan of Correction: The hours of operation that were posted inside the entrance door to the facility are now posted on the outside of the entrance for the general public. The signs on the outside will be checked daily by security when making their rounds and if something happens with the signage will be reported to Program Director . The Program Director will be responsible to assure that they hours remain posted on the outside of the entrance to the facility. |
709.94(c) LICENSURE Project management services
709.94. 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, the facility failed to display a telephone number that can be accessed by the general public in case of an emergency.
The findings include:
A physical plant inspection was conducted on December 18, 2012. A telephone number that is conspicuously displayed to the general public is required at all outpatient treatment programs. The facility did not display an emergency telephone number. An interview with the project director and facility director on December 18, 2012 confirmed the findings.
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Plan of Correction
Plan of Correction: as per the above citation the emergency telephone number that was posted inside the entrance door is now posted along with the hours of operation on the outside of the agency entrance door. Security will check to assure that the posted hours remain on the outside of the entrance on their daily security checks and report any issues with the posted hours immediately to the Program Director. The Program Director will be responsible to assure this corrective action plans is implemented. |