INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 12, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Abstinent Living at the Turning Point at Washington Women With Children Program, 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)(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 the facility's staffing schedules, work hours and First Aid and CPR certification/training cards, the facility failed to provide a sufficient number of staff persons trained in CPR during the project's hours of operation.
The findings include:
The facility's CPR certification and First Aid training cards were reviewed on March 11, 2014. The facility operates as a 24 hour inpatient facility. The facility failed to ensure that a staff person, certified in CPR, was onsite during the project's hours of operation. Specifically, the facility failed to ensure that a staff person certified in CPR was onsite for the overnight shifts on February 3, 10, 17 and 24, 2014. The CPR certification of the staff person on duty during these shifts had expired in November 2013.
The Project/Facility Director was interviewed on March 12, 2014 and confirmed the findings.
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Plan of Correction
The operations manager confirms that a staff member had her CPR and First Aid Certifications expire in November 2013. The operations manager scheduled her for recertification, which she failed to attend. She has been terminated from employment. The operations manager and business manager has informed all applicable staff during the bi-weekly staff meeting of the importance of keeping their certifications up to date, not only to ensure compliance, but also to ensure the safety of our clients. The operations manager and business manager will continue to ensure that all 24 hour staff has been appropriately trained in CPR and First Aid, and that their certifications are kept up to date. This will be overseen by the project director. |
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 a review of the annual report and administrative documentation, the facility failed to make the 2012-2013 annual report available to the public.
The findings include:
Administrative documentation, including the 2012-2013 annual report, was reviewed on March 11, 2014. The facility was required to make the annual report available to the public. The facility failed to make the 2012-2013 annual report available to the public as of March 11, 2014.
The Project/Facility Director was interviewed on March 12, 2014 and confirmed that the annual report had not been made available to the public as of March 12, 2014.
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Plan of Correction
The operations manager confirms that the 2012-2013 annual report was made available once the 2012-2013 audit was completed. The operations manager confirms that this was done beyond the end of the fiscal year. The operations manager and business manager will ensure that the annual report will be made available to the public at the end of the fiscal year. They have communicated this requirement with the accountant and auditor, and will ensure that future annual reports are filed within the time requirements to ensure compliance. This will be overseen by the project director. |
709.51(b)(5) LICENSURE Physical Examination
709.51. Intake and admission.
(b) Intake procedures shall include documentation of:
(5) Physical examination.
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Observations
Based on the review of client records, the facility failed to document a physical examination that included the review of vital signs and/or review of organ symptoms in two of six client records.
The findings include:
Six client records were reviewed on March 12, 2014. Six client records required documentation of a physical examination. The facility did not document a physical examination that included the vital signs and/or review of organ symptoms in client records # 1 and 2.
Client # 1 was admitted on October 1, 2013. The physical, completed on September 10, 2013, did not include a review of the client's organ symptoms.
Client # 2 was admitted on October 25, 2013. The physical, completed on September 5, 2013, did not include the client's vital signs.
The Project/Facility Director was interviewed on March 12, 2014 and confirmed the findings.
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Plan of Correction
The operations manager confirms that for Clients #1 and #2, there was a physical examination done of the client at the treatment center prior to their arrival at our facility. The operations manager also confirms that for those clients, the organ symptoms information was missing on Client #1 and the vital signs was missing on Client #2. The treatment centers that we work with have been informed that all physical examinations done must have all of the appropriate information on them, as required. Additionally, all staff members who conduct assessments and review the information received, have been re-trained as to the information required on the physical evaluations. The operations manager and therapist will continue to ensure that all physical examinations include all required information. This will be overseen by the project director. |