INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on January 2-16, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Caron Treatment Center- Detox Unit 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 employee training records, the facility failed to document the required mandatory communicable disease training for staff in one of two employee records.
The finding includes:
Four employee training records were reviewed during the onsite annual licensure renewal inspection of January 2-16, 2016. Two of four were required to include documentation that they completed four hours of TB/STD training and six hours of HIV/Aids training. One of two employee records failed to include documentation of the required trainings.
Employee # 34 was hired on 6/8/09 and was required to obtain four hours of TB/STD training and six hours of HIV/AIDS training within two years of the date of hire. There was no documentation of the 4 hour TB/STD training and the 6 hour HIV/AIDS training as of January 9, 2013.
The finding was reviewed with administrative staff including the facility director and was not disputed.
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Plan of Correction
- Documentation was found in both charts, however were not seen by the auditor. One was misfiled under the employee's madien name (the files have now been rectified). HR will audit other files to prevent re-occurrence.
- Previous TB/STD training certificates did not indicate all the material covered in the training. A document from the trainer and facility will be added to each file where the certificate is found not to state the complete information.
Training Department will review completed trainings versus required per job description at one year intervals for new hires.
The training director is responsible for implementation and compliance. A copy of Employee #34 certificates were scanned and sent for review. |
705.10 (c) (1) LICENSURE Fire safety.
705.10. Fire safety.
(c) Fire extinguisher. The residential facility shall:
(1) Maintain a portable fire extinguisher with a minimum of an ABC rating, which shall be located on each floor. If there is more than 2,000 square feet of floor space on a floor, the residential facility shall maintain an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based on a physical plant inspection and a review of floor plans depicting square footage and fire extinguisher location in each building on campus, the facility failed to ensure that there is one fire extinguisher for each 2000 square feet of floor space or fraction thereof.
The finding includes:
A physical plant inspection was conducted during the annual licensing renewal inspection of January 2-16, 2013. Floor plan diagrams depicting square footage of each building and fire extinguisher location were reviewed. The floor plan diagrams revealed that fire extinguishers were not installed at the ratio of one for every 2000 square feet of floor space in the following buildings: Medical Building - 6501 Square Feet(SF)- 3 fire extinguishers; Atkins Hall- 6363 SF- 2 fire extinguishers.
The findings were reviewed with maintenance staff and administrative staff including the facility director and were not disputed.
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Plan of Correction
An additional Manual Fire Extinguisher was added in the buildings that was not in compliance. Supporting documentation was forwarded to BDAP on 1/28/13. In order to prevent this from happening in the future the plant standards have been shared and will be shared with the architect for all current and future constructions.
The senior director of Plant Operations is responsible for compliance. This was completed on 1/28/13
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709.26(d)(2) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(2) The results of reference investigations.
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Observations
Based on a review of employee records, the facility failed to document reference checks for each employee as observed in two of four employee records.
The findings included:
The employee records of four staff assigned to the detox unit were reviewed during the annual onsite licensure renewal inspection held from January 2-16, 2013. Two of four employee records failed to include documentation of reference checks for employees assigned to the detoxification unit.
Employee record # 31 - This employee was hired on 4/8/02 and placed in her current position on 4/25/12. No reference results were documented for this employee at the time of inspection.
Employee record # 34- This employee was hired on 6/8/09. No reference results were documented in the record at the time of the inspection .
The findings were reviewed with administrative staff, including the personnel and facility directors and were not disputed.
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Plan of Correction
We checked the files in questions and found the references in the files. A copy of the refrences will be scanned and sent to BDAP for review. In the future we will make sure that the documents are clearly visable in the file when presented for review.
The HR Director is responsible for implementation. |
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 employee records, the facility failed to document annual performance evaluations in a timely manner for two of four employees reviewed.
The finding includes:
Four records of employees assigned to the detoxification unit were reviewed. Two of four employee records failed to include documentation of a timely annual performance evaluation for 2012.
Employee record # 31- This employee was hired 4/8/02 and was placed in her current position on 4/25/12. The annual performance review for 2012 was not documented until 7/31/12.
Employee record # 34- This employee was hired 6/9/09. The annual performance review was not documented until 10/5/12.
The finding was reviewed with administrative personnel including the facility director and was not disputed.
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Plan of Correction
- This has been addressed with the managers of these employees. Completing appraisals in the appropriate time frame will be added as a goal to their performance appraisal.
- Managers are being informed that the expectation is to complete their staffs' performance appraisals by 2 weeks after the employee's anniversary date.
- Notifications from the performance management system will be sent to managers a month and a half prior to the due date.
- Overdue notifications will be sent one week after the appraisal was due and weekly thereafter until the appraisal has been completed.
The Director of HR and Director of Nursing is responsible for implementation. The process was reviewed with all supervisors on Jan. 24th 2013. Implementation went into effect on Jan. 24, 2013. |