INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on April 22 - 23, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Colonial House Inc. 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(c) LICENSURE Core Curriculum - Supervisor Training
704.6. Qualifications for the position of clinical supervisor.
(c) Clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision. Training not provided by the Department shall receive prior approval from the Department.
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Observations
Based on a review of personnel records, the facility failed to ensure clinical supervisors and lead counselors who have not functioned for 2 years as supervisors in the provision of clinical services shall complete a core curriculum in clinical supervision.
The findings include:
One personnel record was reviewed for the position of clinical supervisor on April 22, 2013. The facility failed to ensure that employee # 3 completed the core curriculum training in clinical supervision.
Employee # 3 was hired for the position of clinical supervisor on 10/16/12. Employee # 3 has 4 years of clinical experience and no prior clinical supervisory experience, thus employee # 3 was required to complete a core curriculum in clinical supervision. At the time of review on 4/22/13 employee # 3 did not have the core curriculum training in clinical supervision.
The Project Director confirmed the findings.
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Plan of Correction
704.6 (c)
Clinical Supervisor is scheduled to attend clinical supervision training on June 10th - June 14th, 2013.
All future supervisors will be scheduled at the time of promotion to ensure compliance with this standard.
The Director of Treatment and Human Resources will be responsible for this action |
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 ensure that clinical supervisors participated in documented monthly meeting with their supervisors to discuss their duties and performance for the first 6 months of employment in that position.
The findings include:
One personnel record was reviewed for the position of clinical supervisor on April 22, 2013. The facility failed to ensure that employee # 3 participated in documented monthly supervision for the first 6 months of employment.
Employee # 3 was hired for the position of clinical supervisor on 10/16/12. Monthly supervision was to be documented in November and December 2012, January, February, March, and April 2013.
The Project Director did not dispute the findings.
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Plan of Correction
704.6 (e)
The policy for supervision was reviewed with the Treatment Director on 5/17/2013.
The Treatment Director will schedule and document monthly supervision with the Clinical Supervisor for 6 months.
Both the Treatment Director and Clinical Supervisor will sign the supervision which will be forwarded to the CEO for review.
The CEO will initial and forward to Human Resources to be placed in Personnel Record. |
704.9(b) LICENSURE Performance evaluation
704.9. Supervision of counselor assistant.
(b) Performance evaluation. The counselor assistant shall be given a written semiannual performance evaluation based upon measurable performance standards. If the individual does not meet the standards at the time of evaluation, the counselor assistant shall remain in this status until the supervised period set forth in subsection (c) is completed and a satisfactory rating is received from the counselor assistant's supervisor.
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Observations
Based on a review of personnel records, the facility failed to document performance evaluations in one of two records.
The findings include:
Two personnel records were reviewed for documentation of a performance evaluation on April 22, 2013. The facility failed to document a performance evaluation in one of two records, specifically personnel record # 6.
Employee # 6, a counselor assistant was hired 1/16/12. A written semiannual performance evaluation based upon measurable performance standards was due by 7/16/12 and 1/16/13. There was no documentation of a written semiannual performance evaluation in employee # 6's personnel record.
The Project Director did not dispute the findings.
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Plan of Correction
704.9 (b)
All Counselor Assistants will receive a positive assessment prior to carrying a caseload. The Director of
Treatment will be re-trained on all paperwork requirements by 6/01/2013. The Director of Treatment will ensure that all Counselor Assistants have the appropriate documentation in all personnel records by 6/15/2013. 100 percent of Counselor Assistant personnel records will be audited for six months to ensure completion. The CEO and Director of Treatment will be responsible for this plan of correction |
704.11(a)(4) LICENSURE Evaluation of Overall 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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of administrative documentation and a review of the facility's policy and procedures manual, the facility failed to document an annual evaluation of the overall training plan.
The findings include:
The facility policy states: "The Directors will distribute questionnaires to all staff members requesting their input on areas of training needed for the agency. These questionnaires will be distributed the first week of June. In mid-June, the Directors will hold an annual meeting with staff to compile information from questionnaires, review pertinent training information, review prior years training evaluation and to brainstorm agency-wide training needs. Notes from the meeting will document this."
The facility's training year is from July to June. In accordance with facility policy an overall training plan was to be documented prior to the end of the fiscal year, or by June 30, 2012. Based on a review of administrative documentation on April 22, 2013 the facility failed to document an overall training plan.
The Project Director did not dispute the findings.
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Plan of Correction
704.11 (a) (4)
The CEO and Director of Treatment reviewed requirements of this regulation. All staff will receive a
questionnaire by first week in June and evaluation of all training needs will be completed by 6/15/2013.
This is the responsibility of the CEO. |
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 a review of the facility's policy and procedures manual, the facility failed to document a written individual training plan in five of seven records reviewed.
The findings include:
The facility policy states: "The Directors will meet individually with the staff and complete all individual training assessments and individual training plans. Training plans for each staff member are conducted in June. Each employee signs the training plan."
Seven personnel records were reviewed for documentation of an individual training plan on April 22, 2013. The facility failed to document an individual training plan in five of seven records reviewed; specifically personnel record # 3, 4, 5, 6, and 7.
In addition, the Staffing Requirements Facility Summary Report which was completed by the facility on 4/22/13 documented the individual training plans as "MISSING."
According to the staffing form, the facility also did not document individual training plans for 18 support staff.
The Project Director confirmed the findings.
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Plan of Correction
704.11 (b) (1)
All supervisors will be re-trained on requirements of training plans by 5/27/2013. Training plans for all
existing staff will be completed by 6/19/2013. Annual training plans will be completed upon hire and
annually with performance evaluations. The Human Resources staff member will audit all new hires within 7 days of hire to ensure that training plans are complete. 100 percent of all personnel records will be audited to ensure that every staff member has a training plan. This is the responsibility of the Human Resources staff. |
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 a review of the Staffing Requirements Facility Summary Report, the facility failed to ensure that employee # 5 received a minimum of 6 hours of HIV/AIDS training using a Department approved curriculum.
The findings include:
Six personnel records requiring documentation of 6 hours of HIV/AIDS and 4 hours of TB/STD training were reviewed on April 22, 2013. The facility failed to ensure that one of six employees received 6 hours of HIV/AIDS training, specifically employee # 5.
Employee # 5 was hired as a counselor assistant on 6/1/11. HIV/AIDS training was to have been documented within the first year of employment or by 6/1/12. The facility failed to ensure that employee # 5 received the required 6 hours of HIV/AIDS training.
In addition, the Staffing Requirements Facility Summary Report which was completed by the facility on 4/22/13 supported the above findings.
The Project Director confirmed the findings.
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Plan of Correction
704.11 (c) (1)
An all staff meeting will be held by 6/28/2013. During this staff meeting, staff will be trained on HIV/AIDS using the DDAP Core Curriculum. In addition, in house training will be held for TB/STD by 6/28/2013. Moving forward, this will now be part of our annual training plan so all staff
will be trained via our in-house training program. The Human Resource Department will be responsible for setting up the training. The CEO will ensure that this occurs in the time frame stated. |
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 an interview with the Project Director, the facility failed to provide a sufficient number of staff persons trained in Cardio Pulmonary Resuscitation (CPR) and First Aid (FA) during the project's hours of operation.
The findings include:
On April 22, 2013, copies of staff CPR and First Aid cards and 4 weeks of staff schedules were requested to ensure that the facility had 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. The facility failed to provide the requested documentation.
The Project Director confirmed during an interview that the facility did not have 4 weeks of staff schedules; in addition, the facility was not able to provide CPR and First Aid cards.
Furthermore, the facility failed to ensure that the van drivers were certified in CPR and first aid training.
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Plan of Correction
704.11 (c) (2)
All staff that were out of compliance due to CPR/First Aid training are in compliance as of 4/5/2013.
Upon receiving training, the cards have been printed out and copied so that employee has a card and HR has a copy in all personal files.
All new hires will be sent out to the communtiy for CPR/First Aid training upon hire. That training will be set up by HR upon completing the hire packet. Until they are certified they will not be permitted to work a shift alone.
We have implelmented a CPR/First Aid chart that identifies all trained staff which includes drivers, and those who are not trained, expiration dates.
The schedule for all staff will be completed with the CPR/First Aid training sheet available. All scheduling of drivers, and staff will be done with the CPR/First Aid training sheet in order to maintain compliance.
There is sufficient coverage on each shift of employees that are CPR/First Aid trained
We will be in full compliance by 6/15/13. |
705.10 (a) (1) (iv) LICENSURE Fire safety.
705.10. Fire safety.
(a) Exits.
(1) The residential facility shall:
(iv) Clearly indicate exits by the use of signs.
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Observations
Based on observation during a physical plant inspection, the facility failed to clearly indicate exits by the use of signs.
The findings include:
A physical plant inspection was conducted on April 23, 2013 at 3:30 PM.
It was observed that there was no indication of a second exit.
The facility failed to clearly indicate a second emergency exit in the basement.
The maintenance director confirmed the findings.
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Plan of Correction
705.10 (a) (1) (iv)
A sign was placed above the second exit. Ongoing, the maintenance director will complete a walk-through monthly of the facility to ensure that all physical plant standards are met. |
705.10 (c) (2) (ii) 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.
(ii) The extinguisher shall be located near an exit and away from the cooking area.
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Observations
Based on observation during a physical plant inspection, the facility failed to maintain at least one portable fire extinguisher in the kitchen that was visible and easily accessible.
The findings include:
A physical plant inspection was conducted on April 23, 2013 at 3:30 PM.
It was observed that the kitchen fire extinguisher was not visible and easily accessible.
The kitchen fire extinguisher was located near an exit and away from the cooking area; however, the fire extinguisher was in a tight corner on the side of a large kitchen rack. A broom and dust pan was leaning on the fire extinguisher; in addition, the kitchen rack also had a jacket hanging on it, and the hanging jacket hid the fire extinguisher; therefore the fire extinguisher was not easily visible or accessible
The cook did not dispute the findings.
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Plan of Correction
705.10 (c) (2) (ii)
The policy for fire safety was reviewed with the kitchen staff on 5/17/2013. The cook has been provided space for personal belongings, so that jackets, purses, etc. are not stored in kitchen area. Ongoing, the maintenance director will complete a walk-through monthly of the facility to ensure compliance of this action plan
The fire extinguisher will be moved by 6/14/2013. It will placed in an area that is easily accessible and seen visually.
This will be Kitchen Supervisor responsibilty to maintain 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 a review of personnel records, the facility failed to document fire extinguisher training upon staff employment in one of one record reviewed.
The findings include:
One personnel record was reviewed on April 22, 2013 to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel record # 7.
Employee # 7 was hired 10/22/12.
The training was due upon employment; however the facility did not document the training until 4/15/13.
The Project Director did not dispute the findings.
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Plan of Correction
705.10 (c) (4)
The policy was reviewed with all supervisory staff on 5/17/2013.
All new hired staff will be insrtucted in the use of the fire extinguishers. This will documented in personnel file by the signature of the new hire and the maintance department. Human Resources will audit all new employees within 7 days of hire to ensure compliance with this action plan.
Employee #7 has been trained as of 5/17/2013 |
705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential 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 log, the facility failed to conduct unannounced fire drills at least once a month.
The findings include:
On April 22, 2013, the facility's fire drill log was reviewed covering the period of May 2012 through April 2013. The facility's fire drill log lacked document of fire drills for seven out of eleven months, specifically June, July, August, September, October, December 2012, and March 2013.
The Project Director confirmed the findings.
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Plan of Correction
705.10 (d) (1)
The policy regarding monthly fire drills was reviewed with supervisory staff and maintenance staff on 5/17/2013. All requirements such as documentation of time, exits and methods were reviewed. Maintenance staff will be responsible to complete at minimum one unannounced fire drill per month. The CEO will complete random audits of facility fire drill logs to ensure compliance. |
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 a review of personnel records, the facility failed to ensure that all personnel are trained to perform assigned tasks during emergencies in one of one record reviewed.
The findings include:
One personnel record was reviewed on April 22, 2013 to verify that all personnel were trained to perform assigned tasks during emergencies. The facility failed to document the training upon employment in personnel record # 7.
Employee # 7 was hired 10/22/12.
The training was due upon employment; however, verification of this training was not documented at the time of review on 4/22/13.
The Project Director did not dispute the findings.
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Plan of Correction
705.10 (d) (3)
The policy was reviewed with all supervisors on 5/17/2013. All current staff will be trained on Emergency and Fire Safety procedures by 6/01/2013. All new hires will be trained within 7 days of start, per policy. 100 percent of new hires will be audited for 6 months to ensure compliance. Human Resources will be responsible for this action plan. |
709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Based on an interview with the Project Director, the governing body failed to make available to the public an annual report.
The findings include:
On April 22, 2013, the facility's annual report was requested to ensure that the governing body made the 2012 annual report available to the public.
The facility failed to document or make an annual report available to the public which included:
Activities and accomplishment of the preceding year.
A financial statement income and expenses.
A statement disclosing the names of officers, directors, and principal shareholders, where applicable.
During the inspection and exit interview the Project Director confirmed that the facility did not document an annual report for the 2012 fiscal year.
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Plan of Correction
709.22 (e)
An annual report will be completed for last fiscal year by 6/10/2013. An ad will be placed in the local newspaper for this by 6/15/2013. Ongoing, an annual report will be completed with ad placed by July 15 of each year. The CEO is responsible for this action. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of administrative documentation, the Project Director and governing body failed to develop an annual performance report summarizing the progress toward meeting goals and objectives.
The findings include:
A review of administrative documentation and a conversation with the Project Director on April 23, 2013 confirmed that neither the Project Director nor the governing body developed a performance report summarizing the progress toward meeting the goals and objectives for the Project's 2011 - 2012 fiscal year.
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Plan of Correction
709.23 (b) (3)
Annual Goals will be updated per policy by end of fiscal year. Ongoing, the CEO will update goals and objectives quarterly and present to Governing Body. The CEO is responsible for this action. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of the facility's policy and procedure manual and a review of personnel records, the facility failed to document work performance evaluations in accordance with facility policy.
The findings include:
The facility policy states: "Work performance evaluations will be developed on each employee. This will occur upon the end of probation period. A work performance evaluation will be conducted every 12 months thereafter. The employee's immediate supervisor will schedule a meeting with the employee and present the evaluation orally to the employee. Both will sign and a copy will be placed in the permanent employee personnel file. The clinical supervisor shall develop a written performance evaluation for counselor assistant. This evaluation is presented to the counselor assistant. Evaluation for counselor assistant will be performed at the end of a 6-month probation period and semi-annually until counselor assistant has satisfied qualification of counselor."
Seven personnel records were reviewed for documentation of work performance evaluations on April 22, 2013. The facility failed to document work performance evaluations in accordance with facility policy in three of seven records reviewed, specifically personnel record # 1, 2, and 6.
Employee # 1, the Project Director was hired 5/1/07. A work performance evaluation was due annually, or by 5/1/12. 11/16/11 was the last documented work performance evaluation.
Employee # 2, the Facility Director was hired 7/8/08. A work performance evaluation was due annually, or by 7/8/12. 1/8/12 was the last documented work performance evaluation.
Employee # 6, a counselor assistant was hired 1/16/12. A work performance evaluation was due at the end of a 6-month probation period, or by 7/16/12 and 1/16/13. There was no documentation of a performance evaluation in employee # 6's personnel record.
The Project Director did not dispute the findings.
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Plan of Correction
709.26 (d)(5)(i)
The policy for performance evaluations will be reviewed with all supervisors
by 6/29/2013. All supervisors will complete evaluations upon completion of probation periods, and in May thereafter. Human Resources will be responsible to ensure that each personnel record has the required documentation in the required timeframe. The CEO will complete random audits for 6 months to
ensure compliance
Counselor Assistants and Clinical Supervisor will be completing the performance evaluation in 6 months of hire.
The evaluation for Employee #6 was completed by 5/30/13
Employee #1 will be completed by 6/29/13 by the Board of Directors.
Employee #2 will be completed by 6/29/13. |
709.32(a) LICENSURE Medication Control
709.32. Medication control.
(a) Projects which furnish pharmaceutical services shall comply with all applicable Federal, State and local ordinances, statutes and regulations regarding the storing, compounding, administering or dispensing of medication.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to dispose medication according to policy.
The findings include:
The facility policy states: "Unused medications will be disposed of safely. This destruction must be carried out in the presence of two staff members. This destruction will be documented on the Medication Disposal Form which will then be signed and dated by both staff members who witnessed the destruction."
Based on an interview with the Project Director on April 22, 2013 the facility failed to comply with the policy and procedures manual regarding medication disposal.
The Project Director stated that medication is grounded, mixed with cat litter, and thrown out.
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Plan of Correction
709.32 (a)
The policy and procedure for medication control has been rewritten to state that two staff will sign form for any returned medications. This policy was reviewd and approved by the Board. Any medication that is unused, changed, or discontinued will then be returned to the pharmacy. This new policy will be reviewed with all staff by 6/10/2013. They will sign off on form stating that they have been retrained. All new hires will be trained on this within one week of hire. The Human Resource staff will be responsible for this and the CEO will check quarterly to ensure that it is being followed. |
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
Based on a review of administrative documentation, the facility failed to document an inspection of storage areas in compliance with federal, state and local regulations.
The findings include:
The facility's quarterly inspection inventory was reviewed on April 23, 2013, at approximately 4:30 PM.
The facility failed to maintain a quarterly inspection of storage areas which included:
Disinfectants and drugs for external use are stored separately from oral and injectable drugs;
Drugs requiring special conditions for storage to insure stability are properly stored;
Outdated drugs are removed;
Administration of controlled drugs are adequately documented;
Controlled substances and other abusable drugs are stored in accordance with federal, state and program regulations; and,
Copies of drug-related regulations are available in appropriate areas.
The presented document for the quarterly inspection of storage areas did not include the outlined components. The document was signed and stated "medication area inspected." There was no way of telling of what was inspected.
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Plan of Correction
The policy & procedure for the following requirements for reporting of storage of medication was reviewed with all staff 6/25/2013.
There is a single appointed person responsible for quarterly inspections.Review of the quarterly inspection sheet occurred with the Night Administrator. Employee will identify what area was inspected individually. The column for each area will be signed and dated individually.
Disinfectants will be moved to a separate storage area. Drugs for external use are kept in drawer away from oral and injectable drugs.
There was a new refrigerator purchased on 5/2/2013 for medication required special conditions.
All outdated drugs have been removed in accordance with the FDA suggestion. Going forward medication removal will occur by returning them to the pharmacy and utilizing medication discharge forms. Effective on 5/2/2013.
Administration of Controlled substances are documented first by both staff and client on the MAR. There is another sheet for controlled substances that require staff and client count and then signed off on.
Controlled substances are kept in a lock box within the medication cart that is also locked and in a locked room.
Copies of drug related regulations are posted in medication room for staff to see.
Night Tech Administrator has extensive training in medication and handles this. The quarterly inspection sheet will reviewed by the CEO to insure that the task is being followed correctly by pulling quarterly sheet and checking the information written
The complete plan of correction will be fully executed by 6/25/2013
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709.14(b)(5) LICENSURE Subchapter B.Licensing Procedures.Restriction
709.14. Restriction on license.
(b) The licensee, using Department forms, shall notify the Department within 90 days of the occurrence of any of the following conditions:
(5) Change in authorized maximum capacity.
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Observations
Based on observation during a physical plant inspection and an interview with the Project Director, the facility failed to comply with the maximum approved capacity and failed to notify the Department within 90 days of a change in the authorized maximum capacity.
The findings include:
A physical plant inspection was conducted on April 23, 2013 at 3:30 PM.
The facility is licensed by the Division for a maximum client capacity for 45 inpatient non-hospital drug-free beds.
The facility exceeded the licensed maximum capacity as there were 48 beds in the facility at the time of inspection.
It was observed that the over night staff bedroom had 3 beds. The room contained a bunk bed and a single bed.
The Project Director confirmed the findings.
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Plan of Correction
709.14(b)(5)
As of today, June 11th, 2013 there are 45 beds in the facility. One bed is in the Night Managers sleep quarter. There are 44 client beds in the facility.
The beds were removed from the building.
In order to ensure continued compliance the facility will be at capacity at 44 beds with one staff bed available.
This wil be the responsibilty of the admissions coordinator, maintance and CEO. |