INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 15-16, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Dolminis 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(a)(3) LICENSURE Training Feedback
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:
(3) A mechanism to collect feedback on completed training.
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Observations
Based on a review of staff records, the facility failed to document a mechanism to collect feedback on completed training, as required by regulation.The findings include:Employee records were reviewed on October 2-3 and 16, 2012. The facility failed to document the mechanism to collect feedback after the completion of employee training in employee records # 1, 2, 3, 4 and 5. Although there was documentation that the employees reviewed had attended training in both 2011 and 2012, there was no documentation provided that the employees completed feedback evaluations on the completed training documented in the personnel records. The Facility Director was interviewed on October 16, 2012 and confirmed the findings.
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Plan of Correction
Beginning October 22, 2012, Human resource coordinators will ensure that training evaluations for all trainings are placed in each individual's employee file. Human Resource Coordinators will monitor employee files quarterly to ensure 100% compliance. |
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 required for project director in one of one personnel record.The findings include:Six personnel records were reviewed on October 4-5, 2012. One personnel record pertained to the project director. The facility's training year is January- December. The facility's 2011 training year was reviewed. One personnel record required the completion of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1. Employee # 1 has been the project director since July 1999. There were no training hours documented for the 2011 training year. Human resources personnel were interviewed on October 5, 2012 and confirmed the findings.
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Plan of Correction
Project Manager Training: Project Manager will complete the required 12 hours of training by Nov 30, 2012 . Copies of training certificates will be maintained within his personnel file as evidence of compliance. Human Resource Coordinator will monitor quarterly for ongoing compliance. |
705.24 (5) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(5) Ventilate bathrooms by exhaust fan or window.
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Observations
Based on a physical plant inspection, the facility failed to ventilate the client bathrooms by an exhaust fan or window.The findings include:A physical plant inspection was conducted on October 16, 2012 at approximately 2:30 P.M. The facility has one women's client bathroom and one men's client bathroom. The bathrooms do not have any windows and the exhaust fans in both bathrooms were not operative. The Facility Director was interviewed on October 16, 2012 and confirmed the findings.
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Plan of Correction
The restroom exhaust systems were inspected by maintenance on 10/17/12 and found to be in compliance. A separate on/off switch located beside the light switch was overlooked during the audit.
Ventilation system is in compliance.
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709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based upon a physical plant inspection, the facility failed to have the fee schedule posted in a prominent place. The findings include:A physical plant inspection was conducted on October 16, 2012 at approximately 2:30 P.M. The facility failed to have the fee schedule posted in a prominent place. The Facility Director was interviewed on October 16, 2012 and confirmed the findings.
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Plan of Correction
A sign advertising the client fee schadule has been posted on the client entrance door. Program director will monitor periodically to ensure that sign remains posted. A sign that can be permanently attached to the door will be ordered and displayed by 11/30/12.
Program Director will ensure that permanent sign will be in place by 11/30/12
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709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on the review of client records, the facility failed to document that counseling services were provided according to the individual treatment and rehabilitation plan in five of twelve client records. The findings include: Eighteen client records were reviewed on October 15-16, 2012. Twelve client records were reviewed for compliance with providing counseling services to the client per the individual treatment and rehabilitation plan. The client did not receive counseling services per the individual treatment and rehabilitation plan in client records # 5, 7, 9, 10 and 12. Client # 5 was admitted on July 2, 2012. The individual treatment and rehabilitation plan was completed on July 17, 2012 and the treatment and rehabilitation plan updates stated that the client was to receive two individual counseling sessions and one group counseling session per week. There were no individual counseling sessions documented in July or September, 2012. There was only one individual counseling session documented in August, 2012. There were no group counseling sessions documented in July, August or September, 2012 Client # 7 was admitted on April 4, 2012. The individual treatment and rehabilitation plan was completed on April 25, 2012 which together with the treatment and rehabilitation plan updates stated that the client was to receive two individual counseling sessions and one group counseling session per week. There was only one individual counseling session documented in August 2012. Client # 9 was admitted on May 15, 2012. The individual treatment and rehabilitation plan was completed on June 4, 2012 which together with the treatment and rehabilitation plan updates stated that the client was to receive two individual counseling sessions and one group counseling session per week. There was only one individual counseling session documented in June and July 2012. There were no group counseling sessions documented in June and September 2012. Client # 10 was admitted on August 28, 2012. The individual treatment and rehabilitation plan was completed on September 12, 2012 which together with the treatment and rehabilitation plan updates stated that the client was to receive two individual counseling sessions and one group counseling session per week. There was only one individual counseling session documented in September 2012. There were no group counseling sessions documented in September 2012. Client # 12 was admitted on March 13, 2012. The individual treatment and rehabilitation plan was completed on March 27, 2012 which together with the treatment and rehabilitation plan updates stated that the client was to receive two individual counseling sessions and one group counseling session per week. There were no group counseling sessions documented in June and September 2012. The Facility Director was interviewed on October 16, 2012 and confirmed the findings.
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Plan of Correction
Counselors have been re-trained by the Program Director on how to properly identify counseling services on client treatment plans. Further, the treatment plans have been modified to prompt counselors on accurate completion.
Program Director/Lead Counselor will randomly monitor charts monthly to ensure compliance.
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709.93(a)(11) LICENSURE Client records
709.93. 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 five client records. The findings include:Eighteen client records were reviewed on October 15-16, 2012. Six client records were reviewed as discharged clients. Five discharged clients 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 the completion of follow-up information within 7 days of discharge in client records # 15 and 16 .Client #15 was discharged on June 1, 2012. The follow-up information was to be completed by June 7, 2012. The follow-up was completed on June 20, 2012. Client #16 was discharged on July 11, 2012. The follow-up information was to be completed by July 18, 2012. There was no documentation of follow-up information.The Facility Director was interviewed on October 16, 2012 and confirmed the findings.
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Plan of Correction
Staff has been re-trained by the Program Director on the process for completing follow-up calls within 7 days of discharge.
Program director /lead counselor will monitor all closed charts for completion of the follow-up call by the 7th day of discharge.
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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 the physical plant inspection, the facility failed to display conspicuously to the general public the hours of project operation. The findings include: A physical plant inspection was conducted on October 16, 2012 at approximately 2:30 P.M. There was no posting of the hours of project operation located which were displayed conspicuously to the general public. The Facility Director was interviewed on October 16, 2012 and confirmed the findings.
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Plan of Correction
A temporary sign displaying hours of operation has been posted on the client entrance door. A sign that can be permanently attached to the door displaying hours of operation and emergency information will be ordered and affixed by 11/30/12.
Program director will monitor periodically to ensure that temporary sign remains posted until permanent sign is in place.
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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 the physical plant inspection, the facility failed to display a telephone number which was displayed conspicuously to the general public for emergency purposes. The findings include: A physical plant inspection was conducted on October 16, 2012 at approximately 2:30 P.M. There was no posting of a telephone number located which was displayed conspicuously to the general public for emergency purposes. The Facility Director was interviewed on October 16, 2012 and confirmed the findings.
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Plan of Correction
A temporary sign displaying the emergency phone number was immediately posted on the client entrance door. A sign that can be permanently attached to the door displaying hours of operation and emergency information will be ordered and affixed by 11/30/12.
Program director will monitor periodically to ensure that temporary sign remains posted until permanent sign is in place.
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