INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 6, 2013 by staff from the Program Licensure Division. Based on the findings of the on-site inspection, Innovative Recovery Solutions, 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.
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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
Based on a review of personnel records and the Staffing Requirements Facility Summary Report, the facility failed to ensure that staff persons received 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 in one of one personnel record.
The findings include:
The Staffing Requirements Facility Summary Report and three personnel records were reviewed on August 8, 2013. Employee # 2 was required to have documentation of HIV/AIDS and TB/STD training.
Employee # 2 was hired as a counselor on June 18, 2012. The HIV/AIDS and TB/STD training was to be completed by June 18, 2013. There was no documentation that the employee completed the required trainings.
The Project/Facility Director was interviewed on August 8, 2013 and confirmed the findings.
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Plan of Correction
Facility Director will ensure that all clinical staff complete their required HIV and Other health related topics trainings within one year of hire and all other staff complete the training with in two years of hire as part of their training plan. Facility Director will assist current staff in obtaining the trainings as soon as possible. Facility Director will monitor compliance through employee chart audits. Compliance will be achieved by 9/30/13. |
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 staff employment, in one of one personnel record.
The findings include:
Three personnel records were reviewed on August 6, 2013. One employee required fire extinguisher training upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record #3.
Employee # 3 was hired on September 11, 2012. There was no documentation provided that the employee had completed the fire extinguisher training.
The Project/Facility Director was interviewed on August 6, 2013 and confirmed the findings.
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Plan of Correction
Facility Director will provide an updated Fire Extinguisher training for all current staff and maintain documentation of that training on file for review by 9/30/13 and Facility Director will ensure that all new staff complete the training upon hire and maintain documentation of that training as part of their personnel record. Facility Director will monitor for compliance through random employee chart audits. |
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 to perform assigned tasks during emergencies, in one of one personnel record.
The findings include:
Three personnel records were reviewed on August 6, 2013. One employee was reviewed as a new hire. The facility failed to document the completion of training to perform assigned tasks during emergencies upon staff employment in personnel record # 3.
Employee # 3 was hired on September 11, 2012. There was no documentation provided that the employee had been trained to perform assigned tasks during emergencies.
The Project/Facility Director was interviewed on August 6, 2013 and confirmed the findings.
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Plan of Correction
Facility Director will provide an updated Emergency Procedures training for all current staff and maintain documentation of that training on file for review by 9/30/13 and Facility Director will ensure that all new staff complete the training upon hire and maintain documentation of that training as part of their personnel record. Facility Director will monitor for compliance through random employee chart audits. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to document an individual treatment and rehabilitation plan that included the type and frequency of treatment and rehabilitation services in four of nine client records.
The findings include:
Ten client records were reviewed on August 6, 2013. Nine client records included an individual treatment and rehabilitation plan. The facility failed to document the type and frequency of treatment and rehabilitation services in client records # 1, 2, 3 and 4.
Client # 1 was admitted into treatment on May 23, 2013. An individual treatment and rehabilitation plan was developed with the client on June 22, 2013. The treatment plan did not document the type or frequency of treatment and rehabilitation services.
Client # 2 was admitted into treatment on June 25, 2013. An individual treatment and rehabilitation plan was developed with the client on July 26, 2013. The treatment plan did not document the type or frequency of treatment and rehabilitation services.
Client # 3 was admitted into treatment on December 12, 2012. An individual treatment and rehabilitation plan was developed with the client on January 19, 2013. The treatment plan did not document the type or frequency of treatment and rehabilitation services.
Client # 4 was admitted into treatment on May 16, 2013. An individual treatment and rehabilitation plan was developed with the client on June 15, 2013. The treatment plan did not document the type or frequency of treatment and rehabilitation services.
The Project/Facility Director was interviewed on August 6, 2013 and confirmed the findings.
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Plan of Correction
Facility Director will provide a training related to the inclusion of type and frequency of clinical services as part of each individual patient's treatment plan by 9/30/2013 and will maintain documentation of that training on file for review. Facility Director will monitor for compliance through random patient chart audits. |