INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the January 21, 2010 licensure renewal inspection. The follow-up inspection was conducted on August 18, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the onsite follow-up inspection, Community Counseling Center of Mercer County 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 September 13, 2010.
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Plan of Correction
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704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy and procedure manual and an interview with the facility director/clinical supervisor and the Quality Assurance/Compliance Coordinator, the facility failed to document an annual evaluation of the overall training plan, as required by regulation.
The findings include:
On January 20, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an annual review of the training plan will be completed by July 31. The regulation requires an annual evaluation of the overall training plan to be completed as a component of a staff development program. The facility failed to document the completion of an annual evaluation of the overall training plan for the July 1, 2008 - June 30, 2009 training year.
The facility director/clinical supervisor and the Quality Assurance/Compliance Coordinator was interviewed on January 21, 2010. The facility director/clinical supervisor and the Quality Assurance/Compliance Coordinator confirmed that an annual evaluation of the overall training plan was not completed for the July 1, 2008 - June 30, 2009 training year.
Update: During the plan of correction follow-up visit conducted on 8-18-2010, the annual evaluation of the overall training plan was still not completed for the July 1, 2008 - June 30, 2009 training year. The annual evaluation of the overall training plan was due by July 31. This was confirmed by the clinical supervisor.
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Plan of Correction
In discussion with the reviewer, it was suggested that the Clinical Supervisor be responsible for the previous year training evaluation. This will facilitate the process as the clinical supervisor already does the next years' needs assessment and training plan. The review can be incorporated in the process.
The review for last year will be completed by September 30. In the future, it will be done in accordance with the policy time frame. |
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 personnel records, the facility failed to document the instruction of staff in the use of the fire extinguisher upon employment in one of one personnel records.
The findings include:
Five personnel records were reviewed. One personnel record required documentation of fire extinguisher training. The facility failed to document the completion of fire extinguisher training upon employment in personnel record # 2.
Employee # 2 was hired on November 2, 2009. The training was due in the first week of employment or by November 11, 2009. The training was documented on November 16, 2009, which is more than a week after the hire date.
Update - The time period of observation is insufficient to determine compliance. The facility should resubmit the original plan of correction.
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Plan of Correction
Due to the variety of programs housed under CCC, a monthly training is held for new employees. Since it is held monthly, the HR Director and the Supervisor will make every effort to co-ordinate the first date of hire with the the scheduled training for the month, assuring the training will occur within the time frame required. In the event that this is not possible, an individual training will be provided on the first day of hire to assure comliance.
These changes will be efective immediately, February 22,2010.
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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 a review of personnel records, the facility failed to ensure that all personnel on all shifts are trained upon employment to perform assigned tasks during emergencies, in one of one personnel records.
The findings include:
Five personnel records were reviewed. One personnel record required documentation of emergency training. The facility failed to document the completion of emergency training within the first week of employment in personnel record # 2.
Employee # 2 was hired on November 2, 2009. The training was due within the first week of employment or by November 11, 2009. The training was documented on November 16, 2009, which was beyond the first week of employment..
Update - The time period of observation is insufficient to determine compliance. The facility should resubmit the original plan of correction.
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Plan of Correction
Due to the variety of programs housed under CCC, a monthly training is held for new employees. Since it is held monthly, the HR Director and the Supervisor will make every effort to co-ordinate the first date of hire with the the scheduled training for the month, assuring the training will occur within the time frame required. In the event that this is not possible, an individual training will be provided on the first day of hire to assure comliance.
These changes will be efective immediately, February 22,2010.
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709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
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Observations
Based on a review of administrative polices and procedures and an interview with the Quality Assurance/Compliance Coordinator, the facility failed to document the project director reviewed and updated the written manual delineating project polices and procedures.
The findings include:
The administrative policies and procedures were reviewed on January 20, 2010. The project director failed to document the annual update of the written project policies and procedures, as required by regulation.
The Quality Assurance/Compliance Coordinator was interviewed on January 20, 2010. The Quality Assurance/Compliance Coordinator reports the policy and procedure manual was prepared and annually updated, but could not find documentation that this had occurred.
Update: As of the plan of correction follow-up visit on August 18, 2010, the manual still did not include documentation that the project director signed off on the annual update of the written manual delineating project polices and procedures.
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Plan of Correction
The facility director completed the review of the policy and procedure manual on 8/26/2010.
A notification system has been established to notify the facility Director that a review is due 11 months after the last review. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates in three of five client records.
The findings include:
Eleven client records were reviewed on August 18, 2010. Treatment plan updates are due 60 days from the date of the comprehensive treatment plan. Six of the eleven records were not required to document a treatment plan update. Five of the eleven records were required to document a treatment plan update. Three of the five records that are required to document a treatment plan update had either late or missing documentation. This was noted in records #1, #9, and #10.
The client represented by record #1 was admitted on 4-1-10. A comprehensive treatment plan was completed 5-7-10. The treatment plan update was due 7-7-10 but was not documented until 7-13-2010.
The client represented by record #9 was admitted on 3-25-10. A comprehensive treatment plan was completed 4-6-10. The treatment plan update was due 6-6-10 but was not documented until 6-7-2010. The treatment plan update was due 8-6-10 and was not documented as of August 18, 2010..
The client represented by record #10 was admitted on 3-6-10. A comprehensive treatment plan was completed 4-20-10. The treatment plan update was due 6-20-10. A new treatment plan was completed on 7-30-10, but there was no documentation of a treatment plan update.
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Plan of Correction
On August 19,2010, the D&A treatment team focused on the time frames for preliminary treatment plan, comprehensive treatment plan and up-dates.
Additionally, a cue card with dates was developed and distributed. We are also working on a notification within the EMR for completing the comprehensive plan. |
709.93(a)(8) 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:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within the 60 day time frame in two of three client records.
The findings include:
Eleven client records were reviewed on August 18, 2010. Per agency policy, case consultations shall be completed every 60 days in conjunction with the treatment plan update. Six of the eleven records were not required to include documentation of a case consultation. Three of the eleven records were required to include documentation of a case consultation. Three of the three records that were required to include documentation of a case consultation had missing documentation. This was noted in records #1, #8, and #9.
The client represented by record #1 was admitted on 4-1-10. A case consultation was due on 7-7-10 and was not documented as of 8/18/10.
The client represented by record #8 was admitted on 3-9-10. A case consultation was due on 5-30-10 and documented on 5-27-2010. A case consultation was due on 7-30-10 and was not documented as of 8/18/10..
The client represented by record #9 was admitted on 3-25-10. A case consultation was due on 6-6-10 and was done on 6-7-2010. The case consultation was due 8-6-10 and was not documented as of 8/18/10.
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Plan of Correction
Upon investigation, there appears to have been a period of time when Case Consults were not being included in the documents for the department. When that was corrected, the process was forgotten by some staff.
On August 19,2010 at team meeting, this documentation was reviewed and time frames verified. This was also included on the reminder document |