INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 28, 2013 to January 29, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, WES Corporation 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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704.5(a) LICENSURE Project/Facility Director
704.5. Qualifications for the positions of project director and facility director.
(a) A drug and alcohol treatment project shall have a project director responsible for the overall management of the project and staff and each drug and alcohol treatment facility shall have a facility director responsible for the overall management of the facility and staff unless the project has but one facility.
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Observations
Based on a review of a personnel record and the project's organizational chart, the facility failed to have a project director responsible for the overall management of the project and staff in one of one personnel record reviewed.
The findings include:
From January 28, 2013 to January 29, 2013, one personnel record and the project's organizational chart were reviewed. The facility failed to have a project director responsible for the overall management of the project and staff in one of one personnel record reviewed, specifically, employee # 1.
Employee # 1, the project director, was initially hired by the project on July 16, 2001 and hired for her current position on March 1, 2012. A review of employee # 1's job description indicated that she is Vice President of Program Operations and Chief of Staff but not responsible for the overall management of the project and staff. The job description indicated that employee # 1 is responsible for the day to day effective management of various departments with specific responsibilities relating to project management, media relations and other communications activities, both externally and internally. A review of the project's organizational chart further confirmed that employee # 1 is not responsible for the overall management of the project and staff. The chart indicated that employee # 1 is responsible for the project's Targeted Case Management, Outpatient Services 5 A, Outpatient Services 6 C, Family Based Services, and Substance Abuse. The chart also indicated that the Chief Executive Officer and President of the Board of Directors is the one responsible for the overall management of the project and staff.
The findings were disputed during an interview with the director of quality management on January 29, 2013 at approximately 3:15 P.M. However, the director of quality management was unable to produce documentation that employee # 1 is the one responsible for the overall management of the project and staff.
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Plan of Correction
The Facility Director was informed by the Director of Quality Assurance that the agency have requested an Exception from DDAP to allow the VP of Operations to serve in the role of Project Director.Based on the guidelines, qualifications and definition of PD as indicated in the Licensing Alert 05-05 and from regulations 704.5, our VP of Operations qualifies as the Project Director. If the Exception is granted, the Projcet Director will report to the Board of Directors and the President of the Board. If the exception is not granted, the Board of Directors will identify the apporopriate candidate to fill the PD position based on the feedback and regulation 704.5. The Director of Quality Assurance will continue to monitor for outcomes and to ensure compliance standards are met. |
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 instruct staff in the use of the fire extinguisher upon staff employment in one of four personnel records reviewed.
The findings include:
From January 28, 2013 to January 29, 2013, four personnel records requiring documentation of fire extinguisher training were reviewed. The facility did not provide documentation that they instructed staff in the use of fire extinguisher upon staff employment in one of four personnel records reviewed, specifically, personnel record # 1.
Employee # 1 is the project director and was hired on March 1, 2012. Employee # 1 was due to complete fire extinguisher training upon employment. However, personnel record # 1 did not include documentation of fire extinguisher training as of January 29, 2013.
The findings were confirmed during an interview with the director of quality management on January 29, 2013 at approximately 3:15 P.M.
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Plan of Correction
The Facility Director consulted with the Director of Training and was informed that the Project Director will receive Fire Safety & Disaster Planning training on Tuesday March 12, 2013. Ongoing, the Facility Director will coordinate with the Director of Training to ensure that the Fire Safety & Disaster Training be done within seven days of the hire date for newly hired substance abuse staff. The Facility Director will ensure that the related training certificates are on file upon completion. The Director of Training will continue to monitor for ongoing compliance. |
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 were trained upon employment to perform assigned tasks during emergencies in one of four personnel records reviewed.
The findings include:
From January 28, 2013 to January 29, 2013, four personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility failed to ensure that all employees completed emergency training upon employment in one of four personnel records reviewed, specifically, employee # 1.
Employee # 1 is the project director and was hired on March 1, 2012. Employee # 1 was due to complete emergency training upon employment; however, personnel record # 1 did not include documentation of emergency training as of January 29, 2013.
The findings were confirmed during an interview with the director of quality management on January 29, 2013 at approximately 3:15 P.M.
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Plan of Correction
The Facility Director consulted with the Director of Training and was informed that the Project Director will receive Fire Safety & Disaster Planning training on Tuesday March 12, 2013. Going forward, the Facility Director will coordinate with the Director of Training to have this training done for new hires within seven days of their hire date.
The Facility Director will ensure that the topic related training certificate will be placed in the Training binder upon completion. The Director of Training will continue to monitor to ensure compliance standards are met. |