INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 6-7, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Aldie Foundation Inc. 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 and a plan of correction is due on February 7, 2011.
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Plan of Correction
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705.24 (2) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(2) Provide a sink, a wall mirror, an operable soap dispenser, and either individual paper towels or a mechanical dryer in each bathroom.
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Observations
Based on an inspection of the facility's physical plant and an interview with the Outpatient Coordinator, the facility failed to provide either individual paper towels or a mechanical dryer in each bathroom.
The findings include:
An inspection of the facility's physical plant was conducted on January 7, 2011 at approximately 1:00 PM. The individual client bathroom on the second floor of the facility did not have individual paper towels or a mechanical dryer at the time of inspection.
An interview with the Outpatient Coordinator on January 7, 2011 confirmed that the identified bathroom did not have paper towels or a mechanical dryer.
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Plan of Correction
The office manager will notify the facility's cleaning contractor of the noted deficiency and reiterate their responsibility for maintaining a sufficient supply of paper towels in all of the facility's bathrooms. The office manager will conduct periodic inspections of the bathrooms at least weekly to monitor the contractor's compliance with this requirement. |
705.24 (6) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(6) Provide toilet paper at each toilet at all times.
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Observations
Based on an inspection of the facility's physical plant and an interview with the Outpatient Coordinator, the facility failed to provide toilet paper at each toilet at all times.
The findings include:
An inspection of the facility's physical plant was conducted on January 7, 2011 at approximately 1:00 PM. The individual client bathroom on the second floor of the facility did not have toilet paper at the time of inspection.
An interview with the Outpatient Coordinator on January 7, 2011 confirmed that the identified bathroom did not have toilet paper.
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Plan of Correction
The office manager will notify the facility's cleaning contractor of the noted deficiency and reiterate their responsibility for maintaining a sufficient supply of toilet paper in all of the facility's bathrooms. The office manager will conduct periodic inspections of the bathrooms at least weekly to monitor the contractor's compliance with this requirement. |
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 the review of personnel records and an interview with the Administrative Assistant, the facility failed to document that fire extinguisher training was provided upon employment in two of ten personnel records reviewed.
The findings include:
Ten personnel records were reviewed on January 7, 2011 for documentation of fire extinguisher training. The facility did not document that fire extinguisher training was provided upon employment in personnel records # 9 and 10.
Personnel #9 was hired on 2/22/10, but verification of this training was not documented at the time of review on 1/7/11.
Personnel #10 was hired on 2/22/10, but verification of this training was not documented at the time of review on 1/7/11.
An interview with the Administrative Assistant on 1/7/11, confirmed that personnel records #9 and 10 did not contain documentation of fire extinguisher training provided upon employment.
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Plan of Correction
The operations director shall review new employee training requirements and procedures with supervisory personnel, including the use of the fire extinguisher. The supervisor will verify that the new employee has completed the training via the agency's "Employee Documentation" form.
The administrative assistant responsible for personnel records shall inform the operations director and the applicable supervisor when the required training documentation has not been received for new employees. The operations director will follow-up with the supervisor to ensure that the training is completed and verification submitted to the administrative assistant.
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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 the review of personnel records and an interview with the Administrative Assistant, the facility failed to document personnel trained to perform assigned task during emergencies in two of ten personnel records reviewed.
The findings include:
Ten personnel records were reviewed on January 7, 2011 for documentation of emergency training provided upon employment. The facility did not document that emergency training was provided upon employment in personnel records # 9 and 10.
Personnel #9 was hired on 2/22/10, but verification of this training was not documented at the time of review on 1/7/11.
Personnel #10 was hired on 2/22/10, but verification of this training was not documented at the time of review on 1/7/11.
An interview with the Administrative Assistant on 1/7/11, confirmed that personnel records #9 and 10 did not contain documentation of emergency training provided upon employment.
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Plan of Correction
The operations director shall review new employee training requirements and procedures with supervisory personnel, including performing assigned tasks during emergencies. The supervisor will verify that the new employee has completed the training via the agency's "Employee Documentation" form.
The administrative assistant responsible for personnel records shall inform the operations director and the applicable supervisor when the required training documentation has not been received for new employees. The operations director will follow-up with the supervisor to ensure that the training is completed and verification submitted to the administrative assistant.
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709.84(b) LICENSURE Project management services
709.84. 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 and an interview with the Outpatient Coordinator, the facility failed to display the hours of operation conspicuously to the general public.
The findings include:
A physical plant inspection was conducted on January 7, 2011 at approximately 1:00 PM. The facility was required to display the hours of operation to the general public, but at the time of inspection the hours of operation were not displayed.
An interview with the Outpatient Coordinator on January 7, 2011 confirmed that the hours of operation were not displayed to the general public.
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Plan of Correction
The outpatient coordinator posted the hours of operations at the facility's front entrance, in full view of the general public. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on the review of personnel records, and an interview with the Administrative Assistant, the facility failed to document a performance evaluation in three of four personnel records.
The findings include:
Four personnel records were reviewed on January 7, 2011 for performance evaluations. The facility did not document a work performance evaluation at least once a year, as per facility policy, in personnel records # 2, 3 and 6.
The facility's policy titled " Staff Supervision, Orientation & Evaluation " stated:
"Each employee will be evaluated formally at least once a year on the anniversary of employment. If an employee is assigned a new position with a new pay rate, an evaluation will be conducted at that time. That date then becomes the anniversary on which the annual evaluation will be conducted."
The last documented performance evaluation for Personnel #2 was completed on 2/24/09.
The last documented performance evaluation for Personnel #3 was completed on 7/11/09.
The last documented performance evaluation for Personnel #6 was completed on 1/12/09.
An interview with the Administrative Assistant on January 7, 2011 confirmed that the identified personnel records did not contain a work performance evaluation for the last year of employment.
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Plan of Correction
The operations director will have the administrative assistant in charge of personnel records develop a list each January of staff performance evaluation due dates for the year. This list will be distributed to supervisors. The administrative assistant shall monitor the completion of staff evaluations and inform the operations director when evaluations are not submitted by their due dates so that the director can follow-up with the appropriate supervisor to ensure the completion of the evaluation. |
709.31(b) LICENSURE Uniform Data Collection System
709.31. Uniform Data Collection System.
(b) A data collection and record-keeping system shall be developed that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.
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Observations
Based on a review of the facility's client census reports and an interview with the project director, the facility failed develop a data collection and record keeping system that allows for the efficient retrieval of data needed to measure the project's performance.
The findings include:
The client census reports were reviewed January 7, 2011. The client census reports did not state the date of admission for clients currently enrolled in the program.
An interview with the project director on January 7, 2011, confirmed that the facility's computer system was not currently set up to provide a census report with client admission dates.
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Plan of Correction
The executive director (i.e., project director) has created a separate data field within the agency's electronic data system which has been assigned to specifically track the admission date separate from all other sentinel date fields.
The operations director shall make the appropriate revisions/additions to the agency's applicable policies and procedures to clarify and differentiate the admission date that is to be utilized according to each of the agency's various programs.
The program coordinator shall insure compliance with this procedure through the quality assurance record review process.
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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 the review of client records and a review of the facility ' s policy manual, the facility failed to document a psychosocial evaluation in five of eight client records.
The findings include:
Eight client records were reviewed on January 7, 2011 for psychosocial evaluations. The facility did not document a psychosocial evaluation, as per facility policy, in client records # 2, 3, 5, 6 and 7.
The facility's policy titled "PHASE 3: Treatment Begins" stated:
"Regardless of treatment tract the client may be assigned to, the Primary Therapist is responsible for completing the following paperwork:
Intake Assessment of the client within 30 days of admission.
Treatment Plan and Intake Aftercare Plan within 30 days of admission.
Consults every 90 days. "
The facility did not document an Intake Assessment (psychosocial evaluation) of the client within 30 days of admission in client records #2, 3, 5, 6 and 7.
The admission date for client #2 was 9/30/10, but the psychosocial evaluation was dated 11/14/10.
The admission date for client #3 was 10/29/10, but the psychosocial evaluation was not documented at the time of inspection on 1/7/11.
The admission date for client #5 was 11/4/10, but the psychosocial evaluation was not dated or signed.
The admission date for client #6 was 10/1/10, but the psychosocial evaluation was dated 11/18/10.
The admission date for client #7 was 4/6/10, but the psychosocial evaluation was not documented at the time of inspection on 1/7/11.
An interview with the Outpatient Coordinator on January 7, 2011 confirmed that client records # 2, 3, 5, 6 and 7 did not have a psychosocial evaluation documented in accordance with facility policy.
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Plan of Correction
The operations director will make revisions to the agency's "Internal Utilization Review Policy" to indicate that program coordinators are to increase the number and/or frequency of chart reviews for individual clinicians who have a pattern of continued incomplete or non-compliance with mandated client record documentation, including psychosocial evaluations; and that the clinician will be subject to the agency's policy and procedure on disciplinary action for failure to work at an acceptable quality.
Program coordinators will review the revised policy and procedures with their clinicians and implement it accordingly. The operations director's ongoing supervision of the coordinators will include ensuring that compliance is being either maintained or addressed as needed.
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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 a physical plant inspection and an interview with the Outpatient Coordinator, the facility failed to display the hours of operation conspicuously to the general public.
The findings include:
A physical plant inspection was conducted on January 7, 2011 at approximately 1:00 PM. The facility was required to display the hours of operation to the general public, but at the time of inspection the hours of operation were not displayed.
An interview with the Outpatient Coordinator on January 7, 2011 confirmed that the hours of operation were not displayed to the general public.
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Plan of Correction
The outpatient coordinator posted the hours of operations at the facility's front entrance, in full view of the general public. |