INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 18, 2019 by staff from the Department of Drug and Alcohol Programs, Bureau of Quality Assurance for Prevention and Treatment. Based on the findings of the on-site inspection, Crawford County Drug & Alcohol Executive Commission, 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:
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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
The facility failed to document that all staff completed HIV/AIDS and TB/STD training within the required timeframes.Staff personnel and training records were reviewed on June 18, 2019. Staff records #9 and #10 did not include documentation of HIV/AIDS and TB/STD training within the required timeframes.Staff #9 was hired as a counselor on June 7, 2018. HIV/AIDS and TB/STD training was due to be completed by June 7, 2019. There was no documentation of either training in Staff #9's record.Staff #10 was hired as a support staff on August 2, 2016. HIV/AIDS and TB/STD training was due to be completed by August 2, 2018. There was no documentation of either training in Staff #10's record.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Training plan forms for will be amended by the Facility Director to include a page listing an employee's date of hire, required core trainings, dates core trainings are to be completed by, and dates core trainings are completed. This page will carry forward with the employee and used as a tool for when the Department Supervisor develops their employee's individual training plans. The Department Supervisor will review their employee training plans a minimum of biannually for completion. Any trainings not completed and needed at that point will be reviewed with their immediate supervisor for a plan of attainment. The facility Assistant Director, having already successfully completed DDAP provided 6-hour HIV/AIDS training, will provide the 6-hour HIV/AIDS training to Staff #'s 9 and 10, using the Minimum Content Requirements for Pennsylvania Department of Health Approved HIV/AIDS Curriculum on July 19th, 2019. Staff #'s 9 and 10 have been successfully registered for the 6-hour TB/STD training by a DDAP approved training provider on August 15, 2019. All treatment staff, current and future, will complete the required 6-hour HIV/AIDS and a minimum of 4-hour TB/STD training within one year of hire. All other staff, current and future, will complete the required 6-hour HIV/AIDS and a minimum of 4-hour TB/STD training within two years of hire. |
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
The facility failed to document the exit route used, problems encountered and whether or not the smoke detector / fire alarm was operative on the fire drill log forms for the fire drills conducted during the period of June 2017 - May 2019.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The fire drill form had been altered by a former employee, without Project/Facility Director consent and it did not contain the necessary components required by licensing. The current CFO will recreate the form and the Facility Director will review the form for completeness and immediate use. The CFO will record all fire drills as they occur, and the Facility Director will review and initial the completed fire drill forms to prevent this from occurring again.
The CFO will recreate the Fire Drill Log Form that will include the date, time, exit route(s) used, and operability of the smoke detector(s) and fire alarm(s). The agency will continue monthly fire drills and will complete the Fire Drill Log Form for each fire drill. |
709.30 (1) LICENSURE Client rights
§ 709.30. Client rights.
The project shall develop written policies and procedures on client rights and document written acknowledgement by clients that they have been notified of those rights.
(1) A client receiving care or treatment under section 7 of the act (71 P. S. § 1690.107) shall retain civil rights and liberties except as provided by statute. No client may be deprived of a civil right solely by reason of treatment.
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Observations
The facility failed to document a written acknowledgment by clients that they have been notified of all the required client rights.Client records were reviewed on June 18, 2019. Clients sign an acknowledgment for the receipt of a handbook and orientation packet which include client rights; however, not all of the required client rights are included. in those documents that the client is acknowledging they received. Requirements 709.30(2) - (6) are not included in the documentation provided to the clients.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Case Management Supervisor will update the form "Clients Responsibilities'" to include PA Code 709.30 Client rights and this form will be renamed "Clients Rights and Responsibilities", this will be reviewed during client's assessment. Treatment Manager will update "Client Handbook" to fully reflect PA Code 709.30 Client Rights. Treatment Counselors will review over the Client Handbook during the Admission Session where the client agrees to treatment and verifies that the client has been provided with the Client Handbook, the client signs off on the "Consent to Treatment" which verifies receipt of Client Handbook. Treatment Manager will review Client Handbook and Client Rights and Responsibilities Form to assure adherence to PA Code 709.30 Client Rights. Then these forms will be distribute to treatment and case management supervisors where the supervisors will replace these forms for immediate use. Lastly, the Facility/Project will review process for completeness. . Treatment Supervisors will randomly review client records weekly to ensure the revised forms are being utilized. As a secondary monitoring, treatment supervisors do review over all discharge charts to ensure all appropriate paperwork is being adhere to; treatment counselors when auditing client charts will verify on the audit sheet that the client reviewed and signed off on the "Consent to Treatment" which verifies receipt of Client Handbook. Case Management Supervisors will randomly review assessment paperwork weekly, which includes "Client Rights and Responsibilities" form to ensure that form is being utilized. |