INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 14, 2008 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Renewal 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 and a plan of correction is due on March 18, 2008.
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Plan of Correction
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704.11(c)(2) LICENSURE CPR CERTIFICATION
704.11. Staff development program.
(c) General training requirements.
(2) CPR certification and first aid training shall be provided to a sufficient number of staff persons, so that at least one person trained in these skills is onsite during the project's hours of operation.
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Observations
Based on a review of administrative documentation it was determined that the facility failed to provide a sufficient number of staff persons, so that at least one person trained in CPR certification and first aid training is onsite during the project's hours of operation. The facility failed to provide documentation that the staff person working the 11am to 7 PM shift was certified in CPR and first aid.
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Plan of Correction
Renewal Treatment Inc. has monthly CPR training classes in-house at our faciliities. The Treatment Aid that was working the 11 AM to 7PM shift failed to attend the training. The staff member who was out of compliance was removed from the work schedule until they have the CPR certification. The staff member will be put back on the schedule once certification is recieved by the Clinical Supervisor. This corrective action has already taken place. The Clinical Supervisor scheduled the Treatment Aid to ensure compliance. The Treatment Aid is now certified in CPR and will recieve 1st Aid training today. The Treatment Aid has subsequently been placed back on the schedule. All training files will be audited quarterley to ensure that all staff are adhering to the training requirements. The Director Program Compliance will perform the training file audits to ensure compliance. |
705.10 (c) (4) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(4) Instruct all staff in the use of the fire extinguishers upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on the review of personnel records, the facility failed to document that staff were instructed in the use of fire extinguishers upon employment in three of seven personnel records, #9, 10 and 11. Documentation that the staff had received the training within seven days of hire was missing in all three records.
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Plan of Correction
All staff shall recieve fire extinguisher training as part of their first week of training. This training shall be documented on the new employee orientation checklist which is located in their training file. Scott Johanson, Director of Program Compliance shall ensure that the training is recieved by all new employees and is documented in their training file. Renewal Treatment Inc. will be in full compliance with this regulation. Scott Johanson shall train all new employees and provide training record oversight, Carol Lee Kelly, Clinical Supervisor and Rae Ann Gordon, Clinical Supervisor will document this training using a new employee checklist. This plan of correction is currently in place. |
705.10 (d) (3) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 the review of personnel records, it was determined that the facility failed to document that all personnel on all shifts are trained to perform assigned tasks during an emergency in three of seven client records, #9, 10 and 11. Documentation that they had received training within seven days of hire was missing in all three personnel records.
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Plan of Correction
Renewal Treatment Inc. maintains this documentation in the training files and not the personnel files. All staff shall have emergency plan training as part of their orientation training which is documented on the new employee training checklist. Scott Johanson, Director of Program Compliance shall provide oversight to ensure that this training is provided to all new employees. The emergency plan training will be provided to new staff by Scott Johanson and/or the Security Supervisor. Renewal Treatment Inc. is in full compliance with this requirement. |
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
Based on the review of client records, the facility failed to obtain an informed and voluntary consent for the disclosure of client identifying information in seven of eight client records reviewed, #18, 19, 20, 21, 23, 24 and 25. Consent to release information forms signed by the client stated that information released to a non health care provider or an insurance agency could be re released without the client's consent. This is a violation of federal confidentiality regulations at 42 CFR Part 2, Subpart C, Subsection 2.32.
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Plan of Correction
Renewal Treatment Inc. shall recieve voluntary consent for disclosure of client identifying information. Renewal Treatment Inc. shall change the Consent To Release information forms to comply with federal confidentiality regulations at 42 CFR Part 2, Subpart C, Subsection 2.32. Bill Bernardo, Facility Director, Rae Ann Gordon, Clinical Superviosr and Carol Lee Kelly, Clinical Supervisor shall change the form to ensure compliance, provide training to staff and follow-up to ensure oversight. The form is in the process of being changed, training will be given to staff after the form is completed. This shall all take place by March 21,2008. |