INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 16 - 19, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on a review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of two personnel records.
The findings include:
Twenty-six personnel records were reviewed on June 16, 2014. Two personnel records reviewed were that of the clinical supervisors, #3 and 4. The facility failed to document monthly supervision meetings in personnel record # 4.
Employee # 4 was hired at the project on April 20, 1995 and was promoted to the position of clinical supervisor on August 19, 2013. Monthly supervision meetings were required to take place in August, September, October, November, December and January. There was no documentation of monthly supervision meetings in the personnel record of employee # 4.
A discussion with the facility director took place on June 18, 2014 and she confirmed the findings.
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Plan of Correction
Responsible Party: It is the responsibility of the Program Director to participate in documented monthly meetings with newly appointed Clinical Supervisors for the first 6 months of the supervisors appointment.
Timeframe: The Program Director will schedule monthly supervision with employee #4 beginning 8/1/14.
Monitoring: All monthly supervision sessions with employee #4 will be documented on a supervision note and signed by the employee.
All documented sessions will be maintained in a binder in the Program Director's office.
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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
Based on a review of personnel records and the staffing requirements facility summary report (SRFSR), the facility failed to assure that each employee received a written individual training plan in eighteen of twenty-six personnel records.
The findings include:
The facility's SRFSR and twenty-six personnel records were reviewed on June 16, 2014. Seven personnel records revealed that the Individual training plans only included the mandated training's with time frames. The individual training plans were not specific to each employee training needs, #1, 5, 6, 8, 9, 10, and 11.
Additionally, the facility failed to document individual training plans for training year 2014 in personnel records, #2, 16, 18, 19, 20, 21, 22, 23, 24, 25 and 26.
Employee #2 was hired February 20, 2010 and as of the date of the licensing inspection the facility failed to document the employees individual training plan for 2014.
Employee #16 was hired July 6, 1995 and as of the date of the licensing inspection the facility failed to document the employees individual training plan for 2014.
Employee #18 was hired September 1, 2009 and as of the date of the licensing inspection the facility failed to document the employees individual training plan for 2014.
Employee #19 was hired August 14, 2009 and as of the date of the licensing inspection the facility failed to document the employees individual training plan for 2014.
Employee #20 was hired August 14, 2009 and as of the date of the licensing inspection the facility failed to document the employees individual training plan for 2014.
Employee #21 was hired March 5, 2012 and as of the date of the licensing inspection the facility failed to document the employees individual training plan for 2014.
Employee #22 was hired August 1, 2013 and as of the date of the licensing inspection the facility failed to document the employees individual training plan for 2014.
Employee #23 was hired April 1, 2013 and as of the date of the licensing inspection the facility failed to document the employees individual training plan for 2014.
Employee #24 was hired October 5, 2012 and as of the date of the licensing inspection the facility failed to document the employees individual training plan for 2014.
Employee #25 was hired November 11, 2013 and as of the date of the licensing inspection the facility failed to document the employees individual training plan for 2014.
Employee #26 was hired February 20, 2014 and as of the date of the licensing inspection the facility failed to document the employees individual training plan for 2014.
The findings were confirmed by the facility director on June 18, 2014.
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Plan of Correction
Responsible Party: The supervisor for each staff member is responsible for documenting a written individual training plan appropriate to the employee skill level. Additionally, all plans are to be completed annually.
Time Frame: All outstanding individual training plans for employees #2, 16, 18, 19, 20, 21, 22, 23, 24, 25 and 26 will be completed no later than August 15, 2014.
Ongoing, all plans will be completed annually, no later than January 31st.
Monitoring: The supervisor, in conjunction with the Talent and Stakeholders Support Department, will monitor completion of all annual individual training plans.
They will also monitor training plans specific to each employee's training needs for all future annual training plans.
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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 the facility's staffing requirements facility summary report (SRFSR), the facility failed to ensure that staff persons and/or volunteers 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 as per the regulatory requirements in nine of twenty-six records reviewed.
The findings include:
The facility's SRFSR form completed by the facility on June 16, 2014 was reviewed on June 18, 2014. The form listed nine staff as not having completed the mandatory training within the regulatory time frames.
Employee # 5, a counselor, was hired on October 1, 2012. Employee # 5 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by October 1, 2013. The training was not documented as of the date of the licensing inspection.
Employee # 11, a counselor, was hired on January 7, 2013. Employee # 11 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by January 7, 2014. The training was not documented as of the date of the licensing inspection.
Employee # 13, a support staff person, was hired on July 19, 2011. Employee # 13 was required to obtain 4 hours of TB/STD training by July 9, 2013. The training was not documented as of the date of the inspection.
Employee # 14, a support staff person, was hired on October 21, 2011. Employee # 14 was required to obtain 4 hours of TB/STD training by October 21, 2013. The training was not documented as of the date of the inspection.
Employee # 15, a support staff person, was hired on December 9, 2004 . Employee # 15 was required to obtain 4 hours of TB/STD training by December 9, 2006. The training was not documented as of the date of the inspection.
Employee # 17, a support staff person, was hired on April 15, 2007. Employee # 17 was required to obtain 4 hours of TB/STD training by April 15, 2009. The training was not documented as of the date of the inspection.
Employee # 18, a support staff person, was hired on September 1, 2009. Employee # 18 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by September 1, 2011. The training was not documented as of the date of the inspection.
Employee # 19, a support staff person, was hired on August 14, 2009. Employee # 19 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by August 14, 2011. The training was not documented as of the date of the inspection.
Employee # 21, a support staff person, was hired on March 5, 2012. Employee # 21 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by March 5, 2014. The training was not documented as of the date of the inspection.
The findings were confirmed by the facility director on June 18, 2014.
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Plan of Correction
Responsible: The Clinical Supervisors,Facility Director, Director of Training and the Talent Stakeholder and Support Director are responsible for ensuring that clinical staff persons and volunteers receive a minimum of 4 hours of TB/STD and 6 hours of HIV/AIDS training within 1 year of employment. All other support staff receive the same training within the first 2 years of employment.
Time Frame: Employees #5,11,18,19 and 20 will obtain both HIV/AIDS and TB/STD training by September 30, 2014.
Employees, 13,14,15 and 17 will obtain TB/STD training by Sept 30, 214.
Monitoring: Supervisors will ensure that all clinical employees receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases within the first year of employment, and support staff within 2 years.
The agency is also planning to provide HIV/AIDS and TB/STD training on site at least once every 6 months to ensure all staff in need of these trainings can receive it within the required timeframe.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 12 clock hours of annual training required for project directors in one of one personnel record.
The findings include:
Twenty-six personnel records were reviewed on June 16, 2014. One personnel record pertained to the project director who was required to show documentation of 12 clock hours of annual training. The facility failed to document 12 clock hours of annual training in personnel record # 1.
Employee # 1 has been the project director since December 3, 2001. The facility training year is from January 1 through December 31. Employee # 1 had documentation of 0 hours of training for the January 1, 2013 through December 31, 2013 training year.
The findings were confirmed by the facility director on June 18, 2014.
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Plan of Correction
Responsible Party: The Project Director is responsible for completing and documenting 12 hours of annual training.
Time Frame: The Project Director will document completion of at least 12 clock hours of annual training between January 1 and December 31 of each year.
Monitoring: The licensing and training director along with the administrative assistant to the project director will monitor all trainings completed by the project director beginning August 4, 2014.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 25 clock hours of annual training required for counselors in two of six personnel records reviewed.
The findings included:
Twenty-six personnel records were reviewed on June 18, 2014. Six personnel records reviewed were that of counselors. Two of the six personnel record were required to document the completion of 25 clock hours of annual training. The facility failed to document 25 clock hours of annual training in personnel records # 6 and 7.
Employee # 6 was hired on August 22, 2011. The facility training year is from January through December. The training year for January 2013 to December 2013 was reviewed. Employee # 6 only completed 17 clock hours of annual training in 2013.
Employee # 7 was hired on May 5, 2007. The facility training year is from January through December. The training year for January 2013 to December 2013 was reviewed. Employee # 7 only completed 5 clock hours of annual training in 2013.
The findings were confirmed by the facility director on June 18, 2014.
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Plan of Correction
Responsible Party: The Employee,in collaboration with the Clinical Supervisors and Program Mangers are responsible for ensuring that counselors receive 25 clock hours of training, and submitting verification of the training hours.
Timeframe: All employees, including #6 and 7 will submit all documentation of completed trainings to the TSS dept. within one week of each completed training.
Monthly review, By the Supervisor,for completion of required annual trainings will begin as of August 4 2014.
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704.11(g)(1) LICENSURE Trng Req-Couns Asst
(g) Training requirements for counselor assistants.
(1) Each counselor assistant shall complete at least 40 clock hours of training the first year and 30 clock hours annually thereafter in areas such as:
(i) Pharmacology.
(ii) Confidentiality.
(iii) Client recordkeeping.
(iv) Drug and alcohol assessment.
(v) Basic counseling.
(vi) Treatment planning.
(vii) The disease of addiction.
(viii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Interaction of addiction and mental illness.
(xii) Cultural awareness.
(xiii) Sexual harassment.
(xiv) Developmental psychology.
(xv) Relapse prevention.
(h) Training hours. Training hours are not cumulative from one personnel classification to another.
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Observations
Based on a review of personnel records, the facility failed to document the completion of 40 clock hours of annual training required for counselor assistant in one of one personnel records.
The findings include:
Twenty-six personnel records were reviewed on June 18, 2014. One personnel record pertained to a counselor assistant. Employee #11 was required to have documented the completion of 40 clock hours of annual training. The facility failed to document 40 clock hours of annual training.
Employee # 11 was hired on January 7, 2013. The facility only documented 30 clock hours of annual training for employee #11.
The findings were confirmed by the facility director on June 18, 2014.
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Plan of Correction
Responsible Party: The Employee, in collaboration with the Clinical Supervisors and Program Mangers are responsible for ensuring that counselor assistants receive at least 40 clock hours of training the first year of employment, and 30 clock hours annually. The employee is also responsible for submitting verification of the training hours to the TSS Dept.
Timeframe: All counselor assistants, including #11 will submit documentation of completed trainings to the TSS dept. within one week of each completed training.
Monthly review, by the Supervisor, of the status of required trainings will also begin as of 8/4/14.
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705.28 (c) (3) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(3) Ensure fire extinguishers are inspected and approved annually by the local fire department or fire extinguisher company. The date of the inspection shall be indicated on the extinguisher or inspection tag. If a fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
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Observations
Based on the results of the physical plant inspection, the facility failed to ensure that the fire extinguishers were inspected and approved annually.
The findings include:
The physical plant inspection took place on June 18, 2014 around 2:00 P.M. Fire extinguishers were last inspected during April of 2013.
An interview with facility director on June 18, 2014 confirmed the findings.
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Plan of Correction
Responsible: The Facilities Director is responsible for ensuring that the fire extinguishers are inspected and approved annually by the local fire department, or a fire extinguisher company.
The Director of Facilities will ensure that the date of the inspection is indicated on the extinguisher, or inspection tag.
In addition, if the fire extinguisher is found to be inoperable, it shall be replaced or repaired within 48 hours of the time it was found to be inoperable.
Time Frame: All fire extinguishers in the facility will be inspected and approved no later than July 14, 2014.
Monitoring: The Facilities Director or designated staff will monitor all fire extinguishers to ensure they are inspected and approved as required.
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705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of the facility's fire drill record, the facility failed to document monthly fire drills.
The findings include:
The fire drill record was reviewed on June 16, 2014. The fire drill record was reviewed for the period June 2013 through May 2014. Three of the twelve months did not include documentation that a fire drill was conducted. There was no documentation of fire drills for the months of March 2014, April 2014 and May 2014. Documentation for the months of June 2013, November 2013 and January 2014 indicated that the notification of the fire drill was done either verbally or by 'quiet' notification. There was no approved exception request on file. The facility failed to set off the fire alarm.
An interview with facility director on June 18, 2014 confirmed the findings.
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Plan of Correction
Responsible: The Facilities Director, or designee is responsible for conducting unannounced fire drills at least once per month, while keeping an accurate record of such fire drills.
Time Frame: All unannounced fire drills will be conducted monthly, and a record kept as of July 1, 2014.
Monitoring: The program director will request review of the fire drill record on a bi-monthly basis to review for completed unannounced fire drills conducted.
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705.29 (2) (iii) LICENSURE Child care.
705.29. Child care.
When a nonresidential facility admits children for services or for custodial care, the following requirements apply:
(2) Interior space. The nonresidential facility shall:
(iii) Maintain protective caps over each electrical outlet.
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Observations
Based on the physical plant inspection, the facility failed to maintain protective caps over each electrical outlet in the child care area.
The findings include:
The physical plant inspection took place on June 18, 2014 at around 2:00 pm. During the inspection of the child care area it was observed that two electrical outlets were not equipped with protective caps over the outlets.
An interview with the assistant facility director and maintenance personnel on June 18, 2014 confirmed the findings.
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Plan of Correction
Responsible: The Facilities Director is responsible for ensuring that protective caps are placed over each electrical outlet in the child care area.
Time Frame: Protective caps will be placed over each electrical outlet in the child care area by July 25, 2014.
Monitoring: The facilities workers will monitor the child care room for missing caps over each electrical outlet and replace within 24 hours when necessary.
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715.6(d) LICENSURE Physician Staffing
(d) A narcotic treatment program shall provide narcotic treatment physician services at least 1 hour per week onsite for every ten patients
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Observations
Based on the review of administrative documentation, the facility failed to provide at least one hour of physician time per a week on site for every ten patients for fourteen of the twenty-six weeks reviewed.
The findings include:
Physician time sheets for the weeks between December 1, 2013 through May 25, 2014 were reviewed on June 16, 2014. The documentation provided indicated that there was insufficient onsite physician hours for fourteen of the twenty-six weeks reviewed based on the average census for those weeks.
During the week of December 22, 2013, the patient census was 372 and the facility documented 15.75 of the required 37.2 physician hours.
During the week of December 29, 2013, the patient census was 369 and the facility documented 22.25 of the required 36.9 physician hours.
During the week of January 19, 2014, the patient census was 369 and the facility documented 34.75 of the required 36.9 physician hours.
During the week of February 2, 2014, the patient census was 360 and the facility documented 35.25 of the required 36.0 physician hours.
During the week of February 9, 2014, the patient census was 362 and the facility documented 23 of the required 36.2 physician hours.
During the week of March 30, 2014, the patient census was 344 and the facility documented 30 of the required 34.4 physician hours.
During the week of April 6, 2014, the patient census was 341 and the facility documented 30 of the required 34.1 physician hours.
During the week of April 13, 2014, the patient census was 338 and the facility documented 30 of the required 33.8 physician hours.
During the week of April 20, 2014, the patient census was 335 and the facility documented 30 of the required 33.5 physician hours.
During the week of April 27, 2014, the patient census was 330 and the facility documented 19.5 of the required 33.0 physician hours.
During the week of May 4, 2014, the patient census was 331 and the facility documented 30 of the required 33.1 physician hours.
During the week of May 11, 2014, the patient census was 330 and the facility documented 30 of the required 33.0 physician hours.
During the week of May 18, 2014, the patient census was 325 and the facility documented 30 of the required 32.5 physician hours.
During the week of May 25, 2014, the patient census was 321 and the facility documented 23.5 of the required 32.1 physician hours.
An interview with the facility director on June 16, 2014 confirmed the findings.
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Plan of Correction
Responsible Party(s): The Nursing Supervisor will be responsible for submitting weekly schedules for the narcotic treatment physicians 2 weeks in advance to ensure that the program provides at least 1 hour per week of onsite physician time for every ten patients.
Timeframe: Verification of Physician Staffing schedules will be submitted to the Facility Director two weeks in advance beginning 8/4/14
Monitoring: The Medical Director, Facility Director and Nursing Supervisor will work collaboratively to monitor physician staff time to ensure that the program is providing at least 1 hour per week of onsite physician time for every ten patients at all times.
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715.23(c)(1-7) LICENSURE Patient records
(c) An annual evaluation of each patient 's status shall be completed by the patient 's counselor and shall be reviewed, dated and signed by the medical director. The annual evaluation period shall start on the date of the patient 's admission to a narcotic treatment program and shall address the following areas:
(1) Employment, education and training.
(2) Legal standing.
(3) Substance abuse.
(4) Financial management abilities.
(5) Physical and emotional health.
(6) Fulfillment of treatment objectives.
(7) Family and community supports.
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Observations
Based on a review of patient records, the facility failed to document annual evaluations in two of four patient records.
The findings include:
Ten patient records were reviewed on June 17-18, 2014. Four client records were reviewed for an annual evaluation. The annual evaluation was missing from patient records #5 and 6.
Patient #5 was admitted on March 21, 2006. The facility documented one annual evaluation since the last licensing inspection on April 25, 2013. As of the date of the licensing inspection, the facility failed to document a current annual evaluation.
Patient #6 was admitted on January 2, 2009. As of the date of the licensing inspection, the facility failed to document a current annual evaluation.
An interview with the facility director on June 18, 2014 confirmed the findings.
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Plan of Correction
Responsible Party: The Clinical Counseling Staff and the Clinical Supervisors are responsible for ensuring that an annual evaluation of each patient's status is completed by the patient's counselor and reviewed, dated and signed by the medical director.
Timeframe:
The Facility Director and Clinical Supervisors will train the Clinical Counseling staff regarding the documentation of annual evaluations in the patient record for all clients who have been enrolled in the treatment project for more than one year, by August 15, 2014.
Monitoring:
The Clinical Supervisors will be responsible for providing monthly supervision to Clinical Staff ensuring that annual evaluations are documented in the patient file as required.
The Clinical Supervisors and the Facility Director will review patient records monthly to ensure continued compliance with this standard
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