INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 5, 2007 and November 6, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Kensington Hospital 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 December 7, 2007.
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
The hospital failed to assure that all support staff completed the general training requirements within the first two years of employment.
Findings: Based on a review of the Staffing Requirements Facility Summary Report completed by the hospital on November 1, 2007, one of three employees in the the Addictions Intake Unit did not meet the general training requirements within two years of employment. The intake worker hired on April 4, 2003 did not have the required training verification. An interview with the clinical supervisor and other administrative staff on November 6, 2007 failed to provide documentation of the required training which was due by April 4, 2005.
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Plan of Correction
Staff will be scheduled for the first available training TBA. The Clinical Supervisor will monitor to assure staff attends state mandated training no later than 1/31/08. |
711.63(c)(3) LICENSURE Legal Support Services
711.63. Project management services.
(c) The project shall assist the client in obtaining the following supportive services, when necessary:
(3) Legal.
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Observations
The hospital failed to provide a letter of agreement or progress note entry in patient files in regard to assistance in obtaining legal services. Findings: Based on an interview with the clinical supervisor and a review of the Addictions Unit procedures manual on November 6, 2007 the hospital failed to provide project management services related to legal services.
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Plan of Correction
A Letter of Collaboration for legal services has been obtained effective 11/30/07. The Clinical Supervisor will monitor to ensure all Letters of Collaboration are maintained and updated accordingly. |