INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on August 9 - 10, 2011 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Innovative Recovery Solutions, 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.
|
Plan of Correction
|
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.
|
Observations
Based on a review of personnel records, CPR certification cards and an interview with the project/facility director, the facility failed to ensure that a sufficient number of staff persons were trained in CPR.
The findings include:
Two personnel records and employee CPR certification cards were reviewed on August 9 - 10, 2011. Only one employee has CPR certification. The facility is open Monday - Friday, 5:00 AM - 1:30 PM and Saturday - Sunday, 6:00 AM - 10:30 AM. One employee is not sufficient to provide CPR coverage for these hours of operation. The facility failed to ensure that a sufficient number of staff persons were trained in CPR.
The project/facility director was interviewed on August 10, 2011 at approximately 11:30 AM. The project/facility director confirmed the facility only has documentation of one staff person with CPR certification. The project/facility director reported a second staff member has CPR, but documentation was not available at the time of the review, on August 9 - 10, 2011.
|
Plan of Correction
Facility Director will obtain CPR and/or First Aid Certification from each individual who is currently certified at hire and will maintain up to date records as those individuals obtain new certification dates. Facility Director will ensure that there are certified staff members present for all direct service hours. All CPR Certification for current employees has been obtained and will continue to be maintained immediately. Facility Director will monitor through random employee chart audits. |
704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
|
Observations
Based on a review of personnel records, the staffing requirements facility summary report and an interview with the project/facility director, the facility failed to document the completion of 25 clock hours of annual training required for counselors in one of one personnel records.
The findings include:
Two personnel records were reviewed on August 9, 2011. Two personnel records pertained to employees performing counselor duties. One personnel record required documentation of 25 clock hours of annual training. The other personnel record pertained to a new counselor who was hired after the completion of the 2010 training year. The facility failed to document 25 clock hours of annual training in personnel record # 1.
Employee # 1 was hired on September 21, 2009. Employee # 1 is the project/facility director. Employee # 1 is also the primary counselor for the facility. Per the staffing requirements facility summary report; employee # 1 provided 30 clinical hours per week to a caseload of 22 clients. The facility training year is from January through December. Employee # 1 only completed 9 clock hours of annual training from January 2010 through December 2010. Employee # 1 failed to document 25 clock hours of annual training from January 2010 through December 2010, at the time of the review, on August 9 - 10, 2011.
Employee # 1 was interviewed on August 9, 2011 at approximately 2:45 PM and confirmed the findings.
|
Plan of Correction
Facility Director will monitor staff training to ensure that each individual receives the required number of training hours annually. Facility Director will assist with registration as needed and will offer information regarding trainings as it is obtained. Facility Director will immediately begin to track training hours to ensure compliance. |
709.23(a) LICENSURE Project Director
709.23. Project director.
(a) The project director shall prepare and annually update a written manual delineating project policies and procedures.
|
Observations
Based on a review of the policy and procedure manual and an interview with the project/facility director, the project director failed to document the annual update of a written manual delineating project polices and procedures.
The findings include:
The administrative policies and procedures were reviewed on August 9, 2011. Per regulation, the project director shall prepare and annually update a written manual delineating project policies and procedures. The project director should document the updating by dated signature. Documentation of an annual update of the written project policies and procedures by the project director, was not available at the time of the review, on August 9 - 10, 2011.
The project/facility director was interviewed on August 9, 2011 at approximately 2:30 PM. The project/facility director confirmed that she did not document the annual update of the policy and procedure manual.
|
Plan of Correction
Facility Director will create a sign off sheet which will be signed annually indicating that the Project Director acknowledges all updates which have occurred throughout the previous year. This signature sheet will be available as part of our Policy and Procedure Manuals and available for review. Signature sheet has been created and filed. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
|
Observations
Based on a review of administrative materials and an interview with the project/facility director, the project failed to complete the 2010 audit by the end of the project's fiscal year, as required by regulation.
The findings include:
A review of administrative materials was conducted on August 9, 2011. Per regulation, the project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services. The project's fiscal year is from January through December. The project failed to document the completion of an annual audit for the January through December 2010 fiscal year, at the time of the review, on August 9 - 10, 2011.
On August 9, 2011 at approximately 2:45 PM, the project/facility director confirmed an annual audit has not been completed for the 2010 fiscal year. The project/facility director reported the project is in the process of requesting an exception from the Department.
|
Plan of Correction
Business Manager will submit all required documentation to request an exception as defined in Licensing Alert 01-11 ? Financial Audits. The required information will be submitted within 15 days of approval of this POC and the submission and subsequent decision will be maintained on file for review.
If the exception is not granted, the 2010 audit will be completed by March 31, 2012 and each subsequent year's audit will be completed by June 30 each year. Facility Director will submit necessay information for each audit and ensure each audit is completed by June 30 each year. |
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.
|
Observations
Based on a review of policies and procedures, personnel records and an interview with the project/facility director, the facility failed to document annual performance evaluations as required by facility policy and regulation, in one of one personnel records.
The findings include:
Two personnel records were reviewed on August 9, 2011. One personnel record was required to include documentation of an annual performance evaluation. One employee was new and not yet due for a performance evaluation. Per facility policy and the project/facility director, performance evaluations are conducted annually on the anniversary date of the employee. The facility failed to document an annual performance evaluation in personnel record # 1.
Employee # 1 was hired on September 21, 2009. An annual performance evaluation was due to be completed no later than September 21, 2010. There was no documentation of an annual performance evaluation in personnel record # 1, at the time of the review, on August 9 - 10, 2011.
Employee # 1 was interviewed on August 9, 2011 at approximately 2:30 PM and confirmed a performance evaluation had not been completed.
|
Plan of Correction
Facility Director will complete at a minimum a self-evaluation of their overall annual performance to be maintained as part of their employee record and available for review. Annual Performance Evaluations will be completed within two weeks of the anniversary of the individual's original hire date either by the individual completing a self-evaluation or the Supervisor conducting the evaluation. Current self-evaluation will be completed within 15 days of approval of this POC. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
|
Observations
Based on a review of client records and an interview with the project/facility director, the facility failed to document psychosocial evaluations that provided a composite picture of the individual in relationship to the collected historical information in two of five client records.
The findings include:
Six client records were reviewed on August 9 - 10, 2011. Five client records required the completion of a psychosocial evaluation. One client record was from a time frame outside of the current licensing inspection. Per regulation, a psychosocial evaluation should provide a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation. The facility failed to document psychosocial evaluations that provided a composite picture of the individual in client records # 1 and 6.
Client # 1 was admitted into treatment on May 26, 2011. The psychosocial evaluation was completed on June 4, 2011. The psychosocial evaluation did not include a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
Client # 6 was admitted into treatment on June 2, 2011 and discharged on August 4, 2011. The psychosocial evaluation was completed on July 14, 2011. The psychosocial evaluation did not include a composite picture of the individual in relationship to the collected historical information in order to identify possible relationships, conditions and causes leading to the client's current situation.
The project/facility director was interviewed throughout the licensing process and confirmed the findings.
|
Plan of Correction
Facility Director will provide an in-service training to current clinical staff regarding the nature of the Composite Picture which should be created for each patient. This training will be used with subsequent new hires to ensure an understanding of the Psychosocial Evaluation. Training will be completed by the Facility Director within 15 days of acceptance of this POC and documentation will be maintained on file for review.
Facility Director will monitor evaluations through random monthly chart audits to ensure a composite picture has been created. |