INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on December 14, 2011, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Foundation 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 the 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 TB/STD and other health related topics training using a Department approved curriculum within the required timeframes.
The findings include:
The SRFSR was reviewed on December 14 , 2011. The SRFSR failed to include documentation that two employees, specifically #'s 3 and 4, had received HIV/AIDS and / or TB/STD training as required.
Employee # 3, a director, was hired on June 2, 2008. As of December 14, 2011, there was no documentation that employee # 3 completed HIV/AIDS training using a Department approved curriculum.
Employee # 4, a nurse, was hired on June 8, 2009. As of December 14, 2011, there was no documentation that employee # 4 completed HIV/AIDS and TB/STD training using a Department approved curriculum..
The findings were confirmed during the exit interview attended by the Facility Director, Director of Nursing, Corporate Director, and Quality Director.
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Plan of Correction
Both individuals will be scheduled for the next available training. In addition our training organization has educated supervisors on how to run training reports to identify required trainings. We are also requiring that all agency nurses provide a copy of their training certifications upon hire. In order to prevent re-occurrence this was added to the new employee training check list as a required training that must be completed and verified by the Nursing Director.
Caron's Director of Training and the Director of Nursing is responsible for implementation. The Nursing Manager will conduct quarterly audits to ensure compliance. |
709.26(b)(2) LICENSURE Personnel Management
709.26. Personnel management.
(b) The governing body shall adopt a written policy to implement and coordinate personnel management which includes, but is not limited to:
(2) The dissemination of employment information to project staff.
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Observations
Based on the review of the project's Policy and Procedure Manuals and Human Resource Manual, the project failed to adopt a written policy regarding the dissemination of information to staff members.
The findings include:
The project's Policy & Procedure Manuals and the Human Resource Manual were reviewed from December 5 - 8, 2011. The Licensing Specialist was unable to locate a policy that identified the specific methods that the project used to disseminate information to its staff members. The Corporate Director, Quality Specialist, and Human Resource Generalist were asked to assist in finding the policy but were unable to do so.
The findings were confirmed during the exit interview attended by the Facility Director, Quality Specialist, Human Resource Generalist, and Quality Director.
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Plan of Correction
A written policy regarding the dissemination of information to staff members has been written and will be added to our HR policies. The policy will be approved at our next Leadership meeting in March.
Caron Treatment Center's HR Director is responsible for implementation. |
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 the project's Policy and Procedure Manual and pharmacy inspection records, the facility failed to follow its own policy of having monthly pharmacy inspections conducted.
The findings include:
The Policy and Procedure Manuals were reviewed from December 5 - 8, 2011. The policy on inspection of storage areas specified that the locally contracted pharmacy was to inspect the medication storage areas on a monthly basis.
The pharmacy inspection log was reviewed on December 14, 2011. The log failed to include documentation of a monthly inspection in one out of twelve months reviewed, September 2011.
The findings were confirmed by the Director of Nursing during the exit interview.
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Plan of Correction
This citation was reviewed with our existing pharmacy and a new consultant pharmacist is now representing the pharmacy. We made our consultant aware of our auditing practice. We asked her to schedule her visits early in the month in case something untoward would occur.
Caron's Director of Nursing is responsible for implementation and she will audit the process monthly to ensure compliance.
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