INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on August 15, 2024 through August 16, 2024 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Self Help Movement, Inc. was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of personnel records, the facility failed to ensure that one of thirteen applicable employees 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 within the regulatory timeframe.
Employee # 13 was hired as a support staff member on October 20, 2021 and was due to have the communicable disease trainings no later than October 20, 2023. However, the personnel record contained no documentation of the completion of the HIV/AIDS or TB/STD trainings as of the date of the inspection.
This is a repeat citation from the August 31, 2023 annual licensing renewal inspection.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Director
and/or designee, and the employee's
supervisor will ensure that all
support staff and volunteers receive
6 hours of HIV/AIDS and 4 hours of
TB,STD training within the
time frame required by DDAP. They
will do this by checking quarterly to
ensure that all trainings required are
on the employee's training plan and
are completed within the proper time
frame as well as being documented
in our RELIAS (training) system.
Clinical personnel will receive the
trainings (if they have not already
had it) within the first year of hire.
Any other staff will complete the
training within 2 (two) years of their
date of hire.
Employee #13 is no longer employed. |
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 thirteen personnel records, the facility failed to ensure that one applicable staff member was trained to perform assigned tasks during emergencies prior to being on shift.
Employee # 8 was hired as a counselor on October 4, 2023 and is current in that position. Employee # 8 began working shifts on October 4, 2023, but was not trained to perform assigned tasks during emergencies until January 3, 2024.
This is a repeat citation from the August 31, 2023 annual licensing renewal inspection.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Human Resources Director
and/or designee and employee's
supervisor will ensure that all staff
receive, during orientation (the
first week of hire), fire
extinguisher as well as disaster
training.
The Human Resources Department and supervisor of the department will check the RELIAS system within the first week of hire to ensure that the employee has completed the necessary training to start their shift. The employee will not be permitted to start their shift
until the training in RELIAS has
been completed.
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709.51(b)(6) LICENSURE Psychosocial evaluation
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of nine client records and the facility's policies and procedures, the facility failed to document a psychosocial evaluation within three days of admission, per facility policy, in five applicable records reviewed.
Client # 5 was admitted on November 27, 2023 and was discharged on January 10, 2024. The psychosocial evaluation was not completed until December 2, 2023.
Client # 6 was admitted on May 31, 2024 and was active at the time of the inspection. The psychosocial evaluation was not completed until June 18, 2024.
Client # 7 was admitted on June 4, 2024 and was active at the time of the inspection. The psychosocial evaluation was not completed until June 11, 2024.
Client # 8 was admitted on June 3, 2024 and was active at the time of the inspection. The psychosocial evaluation was not completed until June 10, 2024.
Client # 9 was admitted on July 10, 2024 and was active at the time of the inspection. The psychosocial evaluation was not completed until July 15, 2024.
These finding were discussed with facility staff during the licensing process.
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Plan of Correction
The COO, Clinical Director, Director of Administration and Compliance Officer met to ensure that Self Help Movement would be in compliance with state regulations in that psychosocial evaluations will be started within 72 hours (3 days) of client's admission and will be completed within 5 days of client's admission.
Self Help Movement, Inc. will update its policy to read that psychosocial evaluations will be started within 72 hours (3 days) of client's admission and will be completed within 5 days of client's admission. This will be completed by the Director of Administration.
The compliance officer will monitor admissions for each client and the client's chart in KIPU on a daily basis to ensure that the client's psychosocial is completed within 5 days of admissions.
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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
Based on a review of client records and the facility's policy and procedure manual, the facility failed to ensure a complete client record included information relative to the client's involvement with the project to include case consultation notes, in four of six records reviewed. The facility policy manual indicates that case consultation notes will be completed every 60 days.
Client # 1 was admitted on September 25, 2023 and was discharged on February 6, 2024. A case consultation note was documented on October 16, 2023; however, the record did not contain any additional case consultation notes.
Client # 4 was admitted on December 5, 2023 and was discharged on April 23, 2024. The record did not contain documentation of a case consultation note.
Client # 7 was admitted on June 4, 2024 and was active at the time of the inspection. The record did not contain documentation of a case consultation note.
Client # 8 was admitted on June 3, 2024 and was active at the time of the inspection. The record did not contain documentation of a case consultation note.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The COO,Clinical Director, Director of Administration and Compliance Officer met to ensure that Self Help Movement would be in compliance with state regulations in that case consultation notes will be placed in client charts every 90 days.
Self Help Movement, Inc. will update its policy to read that case consultation notes will be completed every 90 days. This will be completed by the Director of Administration.
Case consults will be completed every 90 days. The counselor and clinical director will be responsible to ensure revised policy is followed by conducting chart reviews.
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