INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on November 15, 2006 through November 16, 2006 by staff from the Division of Drug and Alcohol Program Licensure. The following deficiencies were identified during this inspection and a plan of correction is due on December 12, 2006.
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Plan of Correction
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704.3 (b) LICENSURE Recruitment and Hiring
704.3. General requirements for projects.
(b) The project shall develop a policy that addresses the recruitment and hiring of staff persons who are appropriate to the population to be served. Every effort shall be made to hire staff persons representative of that population.
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Observations
A policy addressing the recruitment and hiring of staff persons who are appropriate and representative of the population to be served was not provided.
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Plan of Correction
The director has placed a Policy 704.3 (b) addressing recruitment and hiring of staff persons who are appropriate and representative of the population to be served. The policy has been drafted therefore, this citation will not happen again. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
The counselor assistant is being supervised by the program director, who is not a full-time clinical supervisor or counselor.
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Plan of Correction
The Director is supervising the counselor assistant due to being short staffed and not having a second clinican available for supervision. An advertisement or position announcement was placed in the Patriot newspaper on 11/19/06 and runs regularly on the agency website. The newspaper ad will run at least once a month until the positon of Counselor is filled. The ad was placed and the corrective date reflects when the ad was placed, however, there is no way to give a date as to when a counselor will be hired. The steps to ensure the deficiency won't happen again is non-existence being that the program has no control over turnover or when a staff person may quit. This facility is prepared to place ads in the newspaper monthly to increase a speedy transition in recruiting staff. The counselor assistant was not hired without there being a qualified counselor. The counselor who was qualified to supervise the counselor assistant resigned, leaving the counselor assistant with no supervisor besides the director. The corrective plan remains that the program will hire a fulltime counselor to supervise the counselor assistant and that the regular practice of not hiring a counselor assistant without there being a qualified counselor will continue to be the standard. A third ad was placed in the Patriot News 1/20/07 and interviews are being scheduled. The program plans to fill the open position of Counselor by February 20, 2007. |
704.10 LICENSURE Counselor Asst Promotion
704.10. Promotion of counselor assistant.
(a) A counselor assistant who satisfactorily completes one of the sets of qualifications in 704.7 (relating to qualifications for the position of counselor) may be promoted to the position of counselor.
(b) A counselor assistant shall document to the facility director that he is working toward counselor status. This information shall be documented upon completion of each calendar year.
(c) A counselor assistant shall meet the requirements for counselor within 5 years of employment. A counselor assistant who has accumulated less than 7,500 hours of employment during the first 5 years of employment will have 2 additional years to meet the requirements for counselor.
(d) A counselor assistant who cannot meet the time requirements in subsection (c) may submit to the Department a written petition requesting an exception. The petition shall describe the circumstances that make compliance with subsection (c) impracticable and shall be approved by both the clinical supervisor or lead counselor and the project director. Granting of the petition will be within the discretion of the Department.
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Observations
The counselor assistant is not currently working toward a degree.
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Plan of Correction
The counselor assistant was hired without knowledge of the requirements of promoting to counselor. Therefore, there has been no action to fulfill the requirements for licensure in section 704.10. Policy 704.10 states that a Counselor Assistant MAY be promoted and outlines the necessary steps to obtain the Counselor position. However, the counselor in question does not wish to be promoted and so the interpretation of the regulations reads as optional. The director discussed the promotion of the counselor with the counselor assistant who has expressed no interest in a promotion or pursuing a degree. The program will submit an exemption request asking for this requirement to be waived considering the staff was hired without notice that she would need to receive a degree in 5 years. The policy regarding the promotion of a counselor assistant was understood to be an option due to the wording of the policy. The agency has set a goal of getting a counselor hired to replace the counselor assistant by February 20, 2007. |
704.11(a)(1) LICENSURE Training Needs assessments
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:
(1) An assessment of staff training needs.
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Observations
An assessment of staff training needs was not documented as per agency policy and did not include employee input.
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Plan of Correction
The Director designed a questionnaire soliciting training ideas, interests, and needs. The Director will administer the questionnaire during the first month of the year and the Dierctor will develop a training plan from the feedback. The questionnaire will be adminstered 1/10/07 and the training plan will be completed by January 31, 2007. Completeting these steps each year will ensure the deficiency does not recur. |
704.11(a)(2) LICENSURE Overall Training 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:
(2) An overall plan for addressing these needs.
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Observations
An overall training plan was not completed. The overall training plan should be based on the assessment of staff training needs and address training subjects, trainers and proposed dates of training.
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Plan of Correction
The training plan which the Director will coordinate will include the training schedule for Catholic Charities, an in-house training schedule, BDAP training schedule, and community trainings throughout the year. Trainers and dates will vary, but will be provided once these schedules are made available. Staff will be assigned and registered for the trainings that would benefit them, which they have expressed an interest, and are most affordable. This plan should be completed by the end of January each year. The plan should be completed by January 31, 2007. |
704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Individual training plans were missing in eleven of eleven personnel records reviewed, #1-11.
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Plan of Correction
Individual plans were not signed by all employees. At the January 10, 2007 staff meeting all staff will be present to complete their plan which the Director will administer. Every January plans will be signed in order to ensure the deficiency does not recur. |
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 required 6 hours of HIV/AIDS training and 4 hours of TB/STD training was missing in one of eleven personnel records reviewed, #8.
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Plan of Correction
Personnel #8 is the Executive Director/CEO of Catholic Charities and does not have any direct contact with the clients at the facility. In addition, the CEO does not provide direct supervision to the Director of the program. See organizational chart. An exception request will be submitted due to the fact that the CEO is far removed from direct contact with clients or any direct supervision of the program director. |
705.6 (3) LICENSURE Bathrooms.
705.6. Bathrooms.
The residential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
The hot water temperature in the bathroom was 125 degrees Fahrenheit.
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Plan of Correction
The maintenance men were contacted and adjusted the water on 1/8/07. The water will be check by the maintenance men once a year to monitor temperature to ensure the deficiency does not recur. |
705.10 (a) (1) (iii) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iii) Maintain each ramp, interior stairway and outside steps exceeding two steps with a well-secured handrail and maintain each porch that has over an 18-inch drop with a well-secured railing.
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Observations
The four stairs leading off the side of the front porch did not have a handrail.
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Plan of Correction
The maintenance men were contacted and informed about the situation regarding the steps. A hand rail will be installed by the end of January. |
705.10 (a) (1) (v) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(v) Light interior exits and stairs at all times.
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Observations
A light switch for the light located in the basement exit stairwell could not be found.
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Plan of Correction
The lightbulb has been replaced. Monthly building inspections will be done by resident assistants to ensure the deficiency does not recur. |
705.10 (c) (2) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(2) Maintain at least one portable fire extinguisher with a minimum of an ABC rating in each kitchen.
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Observations
The fire extinguisher located in the kitchen had a BC rating only.
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Plan of Correction
The Director will contact the fire extinquisher provider and make arrangements for an appropriate piece of equipment. The equipment will be replaced by January 15, 2007. Once it has been replaced the deficiency will not recur. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Only one fire drill was conducted during sleeping hours during the last 12 months.
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Plan of Correction
The first overnight fire drill will be conducted by employee #10 and in 6 months by employee #2. Those two employees have received memos so they can mark it in their calendars. Each month the director will confirm fire drills at staff meeting therefore ensuring the overnight drills are completed. |
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
The project director did not review and update the policy and procedure manual.
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Plan of Correction
An updated page of policy changes and corrections based on Licensure citations will be signed by the Director by January 15, 2007. The policy manual will be updated annually and submitted for board signature, reviewed by the director, by January 31 each year to ensure this deficiency will not recur. |
709.24(a) LICENSURE Treatment/Rehabilitation Management
709.24. Treatment/rehabilitation management.
(a) The governing body shall adopt a written plan for the coordination of client treatment and rehabilitation services which includes, but is not limited to:
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Observations
There was no documentation that the current governing body approved the plan for coordination of client treatment and rehabilitation services.
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Plan of Correction
The Director will update the policy manual annually and complete an Update Page which will be signed by the Director and a representative of the governing body indicating approval of the manual and the updates. These signatures will also indicate approval of the Treatment/Rehabilitation Management which is included in the manual. |
709.26(a) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
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Observations
There was no documentation that the governing body has adopted written personnel policies and procedures.
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Plan of Correction
The Director will update the policy manual annually and complete an Update Page which will be signed by the Director and a representative of the governing body indicating approval of the manual and the updates. These signatures will also indicate approval of the Personnel Management which is included in the manual. |
709.26(a)(11) LICENSURE Personnel Management
709.26. Personnel management.
(a) The governing body shall adopt and have implemented written project personnel policies and procedures which include, but are not limited to:
(11) Employe accidents and safety.
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Observations
The policy and procedure regarding employee accidents and safety did not address who would resolve the safety concern after it was reported.
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Plan of Correction
A policy better outlining how to address accidents and reporting of hazardous concerns was drafted and placed in manual by the Director. It will be reviewed by the Associate Executive Director, the CEO, and Board for approval. The process should be completed by January 31, 2007. |
709.26(b) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
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Observations
There was no documentation that the governing body has adopted the written policy to implement and coordinate personnel management.
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Plan of Correction
The Director will update the policy manual annually and complete an Update Page which will be signed by the Director and a representative of the governing body indicating approval of the manual and the updates. These signatures will also indicate approval of the Personnel Management which is included in the manual. The process should be completed by January 31, 2007. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
The confidentiality policy was missing four of the five areas where client information may be released without consent of the client. Specifically, the policy was missing the reporting of suspected child abuse or neglect, reporting a crime on the premises or against program personnel, research and audit evaluation, and with a good cause court order.
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Plan of Correction
The director changed the policy to reflect and include verbage regarding suspected child abuse or neglect, reporting a crime on the premises or against program personnel, research and audit evaluation, and with a good cause court order. The policy will be changed by January 15, 2007. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
The consent to release information also included language for consent to obtain information. The "obtain from" language must be removed from the consent form since the law and regulation does not address or regulate entities wanting to obtain information. Entities may obtain information without any procedures or requirements.
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Plan of Correction
The director updated all releases to include the removal of "obtain informtion" verbage. Also added, was the wording "revoke verbally." These changes will be completed by January 12, 2007. |
709.28(c)(3) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
The purpose of the release of information was stated as the relationship of the person to the client or the title of the person rather than the actual purpose of the disclosure.
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Plan of Correction
The counselor involved with making the error has been trained again by the director in properly completing releases and her charts will be reviewed monthly by the director to ensure compliance. |
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
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Observations
The policy stated that inspections would occur quarterly; however, the only documented inspections occurred in December 2005 and September 2006.
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Plan of Correction
The pharmacist which Evergreen has the contract had a major death in the family and was not able to honor his scheduled dates to inspect the medication closet. However, the pharmacist has resumed his service and will be inspecting on the following dates: 12/18/06, 3/19/07, 6/19/07, 9/18/07, 12/18/07. The program will follow the schedule, however, if unforeseen circumstances occur again, the program will need to search for a second pharmacist in case of emergency. |
709.32(c)(6) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(6) Inventories.
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Observations
Client medication inventories were being conducted daily by non-licensed staff persons. The only persons legally permitted to handle client medications are physicians, physician's assistants, registered nurses and LPNs.
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Plan of Correction
Medication has stopped being counted by nightshift staff. The director has removed count sheets from the medication log. Once staff has been informed this deficiencey will not recur. This correction was completed 12/29/2007. |
709.53(a)(8) LICENSURE Case Consultation Notes
709.53. 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
Case consultations were missing in five of seven client records reviewed, #2, 6, 8, 9 and 10.
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Plan of Correction
Due to staff shortage, case consluts were not able to be done on a regular basis. However, the director has resumeed the regular cycle of case consultations by including them in bi-monthly treatment team meetings/staff meeting. The director will lead and make sure the case consults are conducted twice a month. The first set of consulations was completed 12/27/07. |
709.53(a)(11) LICENSURE Follow-up information
709.53. 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:
(11) Follow-up information.
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Observations
Follow-up information was missing in two of four client records reviewed, #5 and 10. Follow-up information was incomplete in one of four client records reviewed, #9.
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Plan of Correction
It was the director's understanding that follow ups were done only on clients who were discharged successfully due to premature discharges having no follow up information such as phone or addresses. The director will include follow up forms in all discharge packets and advise staff to use them regardless of the discharge and to use whatever most recent information is available as contact information. Follow up forms will be scheduled for all clients who are discharged by January 15, 2007. |
709.53(a)(12) LICENSURE Work as treatment
709.53. 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:
(12) Verification that work done by the client at the project is an integral part of his treatment and rehabilitation plan.
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Observations
Work therapy was not indicated on the comprehensive treatment plan in five of ten client records reviewed, #3, 4, 5, 6 and 9.
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Plan of Correction
The director will train clinical staff again in vital components of a treatment plan to include "work therapy" such as chores. Charts will be reviewed by the director monthly in order to monitor compliance. All charts were screened 1/5/07. |