INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on October 9, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Center for Addictive Disease - Main Line Affiliates 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 personnel records and the facility's Staffing Requirements Facility Summary Report from, the facility failed to ensure that staff persons received a minimum of 6 hours of HIV/AIDS training and at least 4 hours of STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff.The findings include:On October 9, 2012, two personnel records and the Staffing Requirements Facility Summary Report form were reviewed to verify that employees had HIV/AIDS and STD/TB training within the first year of employment for counselors and counselor assistants and within two years of employment for all other staff. The facility failed to ensure that staff persons received a minimum of 6 clock hours of HIV/AIDS training from a curriculum approved by the Department in one of two personnel records reviewed, specifically, personnel record # 2.Employee # 2 is the facility director and clinical supervisor and was hired on September 25, 2006. Employee # 2 would have been due to complete the HIV/AIDS training by September 25, 2007 from a curriculum approved by the Department. Employee # 2's record did include documentation of several HIV/AIDS trainings that were completed prior to September 25, 2007. However, the HIV/AIDS trainings were not from a curriculum approved by the Department.The findings were confirmed during an interview with the project director on October 10, 2012 at approximately 11:30 A.M.This is a repeat citation. The facility was cited on February 8, 2012 for noncompliance with this standard.
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Plan of Correction
The facility director, employee #2 is scheduled to attend HIV/AIDS training in January which is the next available Department of Drug and Alcohol Programs training. The Program Director is responsible to ensure that employee #2 completes this training 0n January 16th. Additionally, all current staff are compliant with the HIV/AIDS and TB/STD training. Any new staff hired by practice and policy are mandated to obtain the HIV/AIDS and TB/STD trainings within the first year of hire. The Project Director is responsible to review all employee's files on a quarterly basis to ensure compliance. |
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 personnel records, first aid cards and Cardio Pulmonary Resuscitation (CPR) certifications, the facility failed to ensure that a sufficient number of staff persons in first aid and CPR skills are present during all the project's hours of operation.The findings include:On October 9, 2012 the facility's personnel records, a first aid card, and CPR certifications were reviewed. The facility is open Monday through Thursday from 9:30 A.M. to 9:00 P.M. Three staff members had documentation of CPR certification. However, only one staff member, a counselor, had documentation of both first aid training and CPR certification. One staff member is not sufficient to provide sufficient first aid and CPR coverage for the hours of operation.The findings were confirmed during an interview with the project director on October 9, 2012 at approximately 11:30 A.M.
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Plan of Correction
A first aid training is scheduled to be held 12/22/12. All 4 employee's will receive certifications. The Project Director is responsible for ensuring a sufficient number of staff on each shift during the hours of operation. This is accomplished by quarterly review of the scheduling. The facility was found to have a sufficent number of CPR certified staff on each shift and with all CPR staff being First Aid certified as of 12/22/12 the Project Director ensures the hours of operation are covered. |
705.28 (a) (1) (i) LICENSURE Fire safety.
705.28. Fire safety.
(a) Exits.
(1) The nonresidential facility shall:
(i) Ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.
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Observations
Based on observations on October 9, 2012, the facility failed to ensure that stairways, hallways and exits from rooms and from the nonresidential facility are unobstructed.The findings include:A physical plant inspection was conducted on October 9, 2012. It was observed during the inspection at approximately 12:10 P.M. that the emergency exit leading to the rear parking lot was locked. The findings were confirmed during an interview with the facility director on October 9, 2012 at approximately 12:15 P.M.
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Plan of Correction
The Project Director will ask for an exemption based on the safety factor for the Adolescent Mental Health program which shares the office space. The door is equipted to open automatically in case of a fire, and this is tested twice a year. Additionally, all staff members have a key to open the door in the event of an emergency. In the event that an exemption is not granted, the facility dirctor would be responsible to make sure the emergency exit leading to the rear parking lot will be unlocked at all times during the facility's hours of operation on a daily basis. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher 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 instruct staff in the use of the fire extinguisher upon staff employment.The findings include:On October 9, 2012, three personnel records requiring documentation of fire extinguisher training were reviewed. The facility did not provide documentation that they instruct staff in the use of the fire extinguisher upon staff employment in one of three personnel records reviewed, specifically, personnel record # 4.Employee # 4 is a counselor and was hired August 7, 2012. Employee # 4 was due to complete fire extinguisher training upon employment. However, personnel record # 4 did not include documentation of fire extinguisher training as of October 9, 2012. The findings were confirmed during an interview with the project director on October 9, 2012 at approximately 11:30 A.M.
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Plan of Correction
The Facility Direcor will meet with all new hires, including temporary employee's to provide the orientation prior to services being performed. The process is in place as all orientation paperwork including fire extinguisher training is given upon first day of work. The Project Director reviews employee files quarterly to ensure that fire extinguisher training is provided. Employee #4 no longer works at the facility and therefore can not be provided the fire extinguisher training.The records have been checked by the Project Director of all exisiting employee's and all are in compliance with fire extinguisher training. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential 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 on all shifts are trained to perform assigned tasks during emergencies. The findings include:On October 9, 2012, three personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility did not provide documentation of the completion of emergency training in one of three personnel records reviewed, specifically, personnel record # 4.Employee # 4 is a counselor and was hired August 7, 2012. Employee # 4 was due to complete emergency training upon employment. However, personnel record # 4 did not include documentation of emergency training as of October 9, 2012. The findings were confirmed during an interview with the project director on October 9, 2012 at approximately 11:30 A.M.
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Plan of Correction
The Facility Director will meet with all new hires, including temporary employee's to provide the orientation prior to services being performed. The process is in place as all orientation paperwork including a review of tasks in the event of an emergency. The Director will double check each new hire to make sure that the orientation includes a review of tasks responsbility in an emergency was completed. Employee #4 no longer works at the facility therefore the facility cannot provide training to employee #4. All employee files are reviewed quarterly by the Project Director to further ensure compliance. The Project Director has reviewed all exisiting employee files and all are compliant with emergency training. |
705.28 (d) (4) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(4) Maintain a written fire drill record including the date, time, the amount of time it took for evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether the fire alarm or smoke detector was operative.
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Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record that included documentation of the exit route used. The findings include:Fire drill records were reviewed on October 9, 2012. The records were reviewed from the period covering December 2011 to October 2012. The facility did not have documentation for the exit route used in eleven of eleven months reviewed, specifically, December 13, 2011; January 31, 2012; February 7, 2012; March 6, 2012; April 24, 2012; May 21, 2012; June 26, 2012; July 17, 2012; August 15, 2012; August 17, 2012; September 26, 2012, and October 2, 2012.The findings were confirmed during an interview with the project director on October 9, 2012 at approximately 10:42 A.M.
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Plan of Correction
The Office Manger will amend the form which the documentation of the fire drill is gathered to include which exit was used. The Office Manger is responsible to change the form and then review the documentation monthly going forward to ensure the exit used is specifically documented. |
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
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Observations
Based on a review of fire drill records, the facility failed to prepare alternate exit routes to be used during fire drills.The findings include:Fire drill records were reviewed on October 9, 2012. The records were reviewed from the period covering December 2011 to October 2012. The facility did not have documentation for the exit route used in the months reviewed; therefore, there was no way to determine if the facility had prepared alternate exit routes to be used during fire drills.The findings were confirmed during an interview with the project director on October 9, 2012 at approximately 10:42 A.M.This is a repeat citation. The facility was cited on October 11, 2011 for noncompliance with this standard.
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Plan of Correction
The Office Manger will amend the form which the documentation of the fire drill is gathered to include which exit was used. The Office Manger is responsible to change the form, prepare alternative exit routes to be used and then review the documentation monthly going forward to ensure the exit used is specifically documented and is not consistently the same exit, therefore, an alternative was prepared, provided and utilized. |
711.91(b)(6) LICENSURE Psychosocial Evaluation
711.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the facility failed to document a psychosocial evaluation that included an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and/or counselor conclusions/impressions. On October 9, 2012, five records requiring documentation of a psychosocial evaluation were reviewed. The facility did not document a psychosocial evaluation that include an assessment of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and/or counselor conclusions/impressions in three of five records reviewed, specifically, client records # 2, 4 and 5.Client # 2 was admitted August 1, 2012. The psychosocial evaluation was completed on August 1, 2012. However, the psychosocial evaluation did not include an evaluation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, counselor conclusions/impression.Client # 4 was admitted May 31, 2012. The psychosocial evaluation was completed on May 31, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment, and counselor conclusions/impressions. Client # 5 was admitted April 12, 2012. The psychosocial evaluation was completed on April 12, 2012. However, the psychosocial evaluation did not include an evaluation of the client's assets/strengths, support systems, coping mechanisms, negative factors, and attitude toward treatment.The findings were confirmed during an interview with the project director on October 9, 2012 at approximately 3:30 P.M.This is a repeat citation. The facility was cited on October 11, 2011 for noncompliance with this standard.
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Plan of Correction
The Facility Director will provide training to all assessors for improving the quality of documentation to ensure they are completing the assessment including an evaluation of problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, and also including the counselor's conclusions/impressions. Further, the Facility Director will monitor progress on a quarterly basis, reviewing l5% of all psychosocial evaluations for each counselor for 90 days. Counselors who score above 95% will be reduced to random audits, those scoring below 95% will continue quarterly monitoring. |
711.92(c)(1) LICENSURE TX Plan Goals
711.92. Treatment and rehabilitation services.
(c) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment, as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the short-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan. The findings include:On October 9, 2012, five client records requiring documentation of short-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the short-term goals for treatment in five of five records reviewed, specifically, client records # 1, 2, 3, 4, and 5.Client # 1 was admitted May 31, 2012. The individual treatment and rehabilitation plan was completed on July 26, 2012, but it did not include documentation of the short-term goals for treatment as of October 9, 2012.Client # 2 was admitted August 1, 2012. The individual treatment and rehabilitation plan was completed on August 2, 2012, but it did not include documentation of the short-term goals for treatment as of October 9, 2012. Client # 3 was admitted February 6, 2012. The individual treatment and rehabilitation plan was completed on March 5, 2012, but it did not include documentation of the short-term goals for treatment as of October 9, 2012. Client # 4 was admitted May 31, 2012. The individual treatment and rehabilitation plan was completed on May 31, 2012, but it did not include documentation of the short-term goals for treatment as of October 9, 2012. Client # 5 was admitted April 12, 2012. The individual treatment and rehabilitation plan was completed on May 14, 2012, but it did not include documentation of the short-term goals for treatment as of October 9, 2012. The findings were confirmed during an interview with the project director on October 9, 2012 at approximately 3:30 P.M.
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Plan of Correction
The facility will change the form for documenting the treatment plan. The new form will include both short term and long term goal delineation. The Facility Director is responsible to educate clinicians and implement new treatment plan. The Facility Director will be responsible for reviewing the treatment plans monthly to ensure that the treatment plans include documentation of both short-term and long-term goals.
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711.93(a)(6) LICENSURE Aftercare Plans
711.93. Client records.
(a) Record requirements. There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. In addition to the requirements in 115.32 (relating to contents), the client record shall include the following:
(6) Aftercare plans, if applicable.
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Observations
Based on a review of client records, the facility failed to document an aftercare plan.The findings include: The facility's policy titled: "Aftercare Policy - Outpatient & Intensive Outpatient," states:"Aftercare is an important part of the continuum of treatment. It shall be the responsibility of the primary therapist to work with the patient on developing an aftercare policy. This shall be done with the patient at the end of the treatment process, when that patient will "move on" from this formal treatment."On October 9, 2012, two client records requiring documentation of an aftercare plan were reviewed. The facility did not document an aftercare plan in two of two records reviewed, specifically, client records # 6 and 10. Client # 6 was admitted September 14, 2011 and was discharged May 25, 2012. The aftercare plan was due by May 25, 2012. However, client record # 6 did not include documentation of an aftercare plan as of October 9, 2012.Client # 10 was admitted July 13, 3011 and was discharged April 11, 2012. The aftercare plan was due by April 11, 2012. However, client record # 10 did not include documentation of an aftercare plan as of October 9, 2012. The findings were confirmed during an interview with the project director on October 9, 2012 at approximately 3:30 P.M.
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Plan of Correction
A Staff meeting was held 10/11/12 where the importance of Aftercare planning was addressed. The procedure was reviewed and discussed with staff. Each staff meeting for the next 6 months will being with a reminder that Aftercare is essential in ongoing recovery and must be performed with the client. The Facility Director will be responsible to conduct these staff meetings and will also review charts randomly at discharge every quarter to ensure compliance.
Aftercare plans are not able to be completed as the clients have both discharged. |
711.94(e) LICENSURE Follow-up Policy
711.94. Project management services.
(e) The project shall develop a written client follow-up policy.
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Observations
Based on a review of the facility's policy and procedures manual, the facility failed to failed to develop a written client follow-up policy that address when clients have been discharged and referred to an outside resource, have successfully completed treatment and discharged, and all other clients who are not administratively discharged.The findings include:On October 9, 2012, the facility's policy and procedures manual was reviewed. The facility's follow-up policy did not address when clients have been discharge and referred to an outside resource, have successfully completed treatment and discharged, and all other clients who are not administratively discharged. The facility's policy titled: "Follow-Up Policy - Outpatient & Intensive Outpatient," states:"Follow-up is a means to determine the following:Determine the patient's status in regards to their recovery. Determine patient satisfaction with the treatment experience here at CAD in both Outpatient and Intensive Outpatient Programs. For those patients completing their CAD treatment successfully, this will be done using the Patient Satisfaction Surveys on their last day of treatment. For those patients who do NOT complete, but are administratively discharged, the Patient Satisfaction Survey will be mailed out within 30 days of their day of discharge. All surveys, either mailed to the patient or given to them to complete on their last day, will be documented in a binder showing the patient name, the date of discharge, and the date the survey was completed/mailed. Returned surveys will be filed in the same binder under the month in which they were completed or returned."The findings were confirmed during an interview with the project director on October 9, 2012 at approximately 3:30 P.M.
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Plan of Correction
The follow-up policy was revised and approved by the project director 11/12/12. The revised follow-up policy addresses when clients have been discharge and referred to an outside resource, have successfully completed treatment and discharged, and all other clients who are not administratively discharged. The Project Director will ensure that the revised policy remains in place at the facility.
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