INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on May 13, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, RHD/New Start II was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility.
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Plan of Correction
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704.6(e) LICENSURE Supervisory Meetings
704.6. Qualifications for the position of clinical supervisor.
(e) Clinical supervisors are required to participate in documented monthly meetings with their supervisors to discuss their duties and performance for the first 6 months of employment in that position. Frequency of meetings thereafter shall be based upon the clinical supervisor's skill level.
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Observations
Based on the review of personnel records, the facility failed to document that the clinical supervisor participated in monthly meetings with their supervisor to discuss their duties and performance for the first six months of employment in that position in one of one personnel record.
The findings include:
Personnel records were reviewed on May 13, 2014. One personnel record reviewed was that of a newly hired clinical supervisor. The facility failed to document the first six months of supervision in personnel record # 6.
Employee # 6 was hired April 21, 2013. The only documented supervision meetings were for the months of May 2013, July 2013, August 2013, January 2014 and March 2014.
An interview with the facility director on May 13, 2014 confirmed the findings.
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Plan of Correction
Beginning June 1, 2014, the Clinical Supervisor will receive monthly supervision that will be documented and housed in the personnel record. Each supervision meeting will address performance and discuss assigned duties. Moving forward, the first six months of supervision for a newly hired Clinical Supervisor will be documented and located in the personnel record, along with ensuing monthly supervision meetings. Director will monitor for ongoing compliance. |
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 facility's 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 tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum as per the regulatory requirements in one of seven records reviewed.
The findings include:
The facility's SRFSR form completed by the facility on May 12, 2014 was reviewed on May 13, 2014. The form listed one staff as not having completed the mandatory training within the regulatory time frames
Employee # 7, a counselor, was hired on April 8, 2013 Employee #7 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by April 8, 2014. The training was not documented as of the date of the inspection.
The findings were confirmed by the facility director on May 13, 2014.
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Plan of Correction
Beginning June 1, 2014, per the regulatory requirements, all staff persons and/or volunteers will received 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. Staff persons that have not received training are scheduled for August 13, 2014 for HIV/AIDS. Staff will attend TB/STD training on July 29, 2014. Director will monitor for ongoing compliance. |
705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility ' s fire drill record, the facility failed to conduct a fire drill during sleeping hours at least once every six months.
The findings include:
The fire drill record was reviewed on May 13, 2014. Documentation of a fire drill conducted during sleeping hours is required once every six months. The fire drill record was reviewed from June 2013 through April 2014. During that time frame, the facility documented two overnight fire drills during sleeping hours June 2013 and April 2014. The facility failed to document an overnight fire drill at least once every six months.
This was discussed with and confirmed by the facility director on May 13, 2014.
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Plan of Correction
Beginning June 1, 2014, New Start II Residential facility will conduct 2 fire drills during sleeping hours at least every 6 months. For the year 2014-2015, the Fire Drill Log will record monthly drills, including those that will occur during sleep hours. Overnight drills will occur during the month of November 2014 and May 2015. A new Fire Drill Log was created that will record the dates and times of drills. All new and current staff will receive and overview on how to conduct and document a fire drill at the next all-staff meeting on June 26, 2014. Director will monitor for ongoing compliance. |
709.28(c) LICENSURE Confidentiality
709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent shall be in writing and include, but not be limited to:
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Observations
Based on a review of client records, the facility failed to document an informed and voluntary consent in four of ten records reviewed.
The findings include:
Ten client records were reviewed on May 13, 2014. The facility failed to document an informed and voluntary consent in client records #1, 3, 4, 6, 9 and 10.
Client record #5 lacked an informed and voluntary consent for the client's emergency contact as the form did not indicate what was to be released and the purpose of the release.
Client record #6 lacked an informed and voluntary consent. Client #6's record contained documented consent to release forms for two agencies. One consent form failed to include documentation as to what was being released, the purpose for the release and the dates the release was signed by the client and witness. The second consent failed to include the dates the release was signed by the client and witness.
Client record #7 lacked an informed and voluntary consent. Client #7's record contained documented consent to release forms for several agencies. One consent form dated 9/27/13 failed to include what was being released, the purpose for the release and the date when the witness signed the consent. The second consent form dated 9/27/13 failed to have documented the date the client signed the consent. The third one dated 9/17/13 failed to include what was being release and the purpose for the release. The last consent form dated 9/17/13 failed to include what was being release, the purpose for the release and the date the client signed the consent.
Client record #8 lacked an informed and voluntary consent. Client record #8 contained two consent to release forms for the client's funding sources dated 9/10/13. Both failed to include the date the client signed the releases. The other two consents dated 9/10/13, failed to have documented what was being release and the purpose for the releases.
The findings were confirmed by the facility director on May 13, 2014.
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Plan of Correction
Beginning June 1, 2014, per regulatory requirements, New Start II will obtain an informed and voluntary consent from each client for the disclosure of information contained in the client record. The written consent will include, but not be limited to: emergency contact, the purpose of the release, what information is to be released, the date the release was signed, appropriate signatures, and source the information is to come from. Initial consents will be completed at client intake and as needed throughout treatment at New Start II. Staff will be trained regarding the proper completion of Consent Forms. An in-house training will occur on June 26, 2014 at the scheduled all staff meeting. Client record reviews will occur monthly in order to provide quality assurance. Director will monitor for ongoing compliance. |
709.53(a) LICENSURE Complete Client Record
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
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Observations
Based on a review of client records, the facility failed to document a complete client record in six of ten records reviewed.
The findings include:
Ten client records were reviewed on May 13, 2014. The facility failed to provide a complete client record for the following clients, #1, 3, 4, 6, 9 and 10.
Client record #1 lacked documentation as to why the client did not take their medication as prescribed. Client #1 was prescribed Amitriptyline HCL 50 mg and was required to take two tablets by mouth every day. Client #1's medication record lacked documentation as to why the client did not take their medication on May 1-3, 2014. Additionally, client #1 was prescribed Mirtazapine 45 mg tablet and was required to take one tablet by mouth once a day at bedtime. Client #1's medication record failed to document why the client did not take their medication on May 11, 2014.
Client record #3 lacked documentation as to why the client did not take their medication as prescribed. Client #3 was prescribed Abilify 15 mg tablet and was required to take one tablet by mouth every day at bedtime. Client #3's medication record failed to document why the client did not take their medication on May 4, 2014. Additionally, client #3 was prescribed Citalopram HBR 20 mg and was required to take one tablet by mouth daily at bedtime. Client #3's medication record failed to document why the client did not take their medication on May 4, 2014.
Client record #4 lacked documentation as to why the client did not take their medication as prescribed. Client #4 was prescribed Lisinoporil-HCTZ 20-25 mg and was required to take one tablet by mouth once daily at 8am. Client #4's medication record failed to document why the client did not take their medication on May 11, 2014.
Client #6 lacked was admitted on September 12, 2013 and discharged on December 3, 2013. The facility failed to document a follow-up attempt in client record #6.
Client #9 was admitted on 2/26/14 and discharged on 4/12/14. The facility failed to document a follow-up attempt in client record #9.
Client #10 was admitted on 12/4/13 and discharged on 4/2/14. The facility failed to document a follow-up attempt in client record #10.
The findings were confirmed by the facility director on May 13, 2014.
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Plan of Correction
Beginning June 1, 2014, New Start II will maintain a complete client record on an individual which includes information relative to the client's involvement with the project. Records will include, but not be limited to, the following: an explanation of why medication was not taken, and documented follow-up attempts after client discharge. Weekly, beginning June 1, 2014, the Assistant Director will meet with the Recovery Specialist to review Medication Logs for completion. All staff will register to attend Medication Management training in August with RHD Miniversity. Director will monitor for ongoing compliance.
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