INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 26-27, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Mcp/Caring Together 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 May 22, 2010.
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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 the review of personnel records and an interview with the facility director, the facility failed to document CPR and First Aid training to a sufficient number of staff persons.
The findings include:
Four personnel records were reviewed and an interview with the facility director was conducted on April 26-27, 2010. The facility did not document CPR and First Aid training to a sufficient number of staff persons. CPR Certification and First Aid certification was not documented in any of the personnel records reviewed.
The facility director confirmed that they did not have any employees with current CPR or First Aid Certification.
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Plan of Correction
Program Manager will ensure that 2 staff persons will be CPR certified by May 27, 2010. Program Manager will further monitor CPR status to ensure prompt renewal of same. |
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, the facility failed to document that fire extinguisher training was provided upon employment in one of four personnel records reviewed.
The findings include:
Four personnel records were reviewed on April 26-27, 2010. All four records required documentation that fire extinguisher training was provided upon employment. The facility did not document that fire extinguisher training was provided upon employment in personnel record # 3.
Personnel # 3 was hired on 8/6/09, but verification of this training was not documented at the time of review on 4/27/09.
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Plan of Correction
Program Manager has trained and tested employee #3 in fire extinguisher use. Going forward, program manager will adminster this training upon the first day of a new employee's beginning at program. |
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, the facility failed to ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
The findings include:
Four personnel records were reviewed on April 26-27, 2010. All four records required documentation to verify that all personnel on all shifts were trained to perform assigned tasks during emergencies. The facility did not document that emergency training was provided upon employment in personnel record # 3.
Personnel # 3 was hired on 8/6/09, but verification of this training was not documented at the time of review on 4/27/09.
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Plan of Correction
Program Manager has trained and tested employee #3 in emergency procedures. Going forward, program manager will adminster this training upon the first day of a new employee's beginning at program. |
711.93(a)(4) LICENSURE Progress Notes
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(4) Progress notes.
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Observations
Based on the review of client records, the facility failed to document progress notes in six of six client records.
The findings include:
Six client records were reviewed on April 26-27, 2010. All six records required documentation of progress notes. The facility did not document group progress notes to include data, assessments and plans relative to treatment in client records # 1, 2, 3, 4, 5 and 6.
In group progress notes, the data portion of the progress note did not include information presented by the client during the counseling session, counselor observations, or information about the client from other sources. The data portion of the group progress notes only contained the topic of the group.
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Plan of Correction
Program Manager to provide a training for staff persons regarding group progress note documentation within two weeks from date of POC and Program Manager will perform random chart audits on a monthly basis to ensure standard is being met. |
711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on the review of client records and an interview with the facility director, the facility failed to document an aftercare plan in two of two client records.
The findings include:
Six client records were reviewed and an interview with the facility director was conducted on April 26-27, 2010. Two of the six records indicated the client graduated from the program, so documentation of an aftercare plan was required. The facility did not document an aftercare plan within 14 days of discharge, as stated in the projects policy manual in client records # 6 and 7.
The project ' s policy titled " Aftercare Plan " states:
The aftercare plan is developed no later than seven (7) days after admission and will be reviewed and amended as needed within 14 days of planned discharge.
Client record # 5 graduated from the program and was discharged on 12/18/09, but the aftercare plan that was completed at intake had not been updated at discharge.
Client record # 6 graduated from the program and was discharged on 12/18/09, but the aftercare plan that was completed at intake had not been updated at discharge.
The facility director confirmed that the aftercare plans had not been updated.
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Plan of Correction
Program Manager has reviewed the program policy regarding aftercare documentation procedures with staff and highlighted state requirements as well. Going forward, Program Manager will spot check client records for impending planned discharges prior to discharge to insure compliance with updating of AC plans. |