INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 20, 2018 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Good Works Life Recovery House 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)(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
The facility failed to document that at least one person with CPR certification was onsite during the project's hours of operation.Staff schedules were reviewed on February 20, 2018. Employee #4 was hired on 6/3/17 as a support staff that provides overnight and/or weekend coverage for the residential treatment facility. Employee #4 had several shifts as sole coverage. Employee #4 did not have documentation of full CPR certification.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
All employees including new hires will have training plans completed per project policy and procedures aligned with licensing standards 704.11 (2) CPR and First Aid Training. There will be at least (1) staff person that is certified in CPR and First Aid Training onsite during all hours of operation. This will be monitored quarterly by the facility director. |
709.33 (a) LICENSURE Notification of termination.
§ 709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client ' s treatment at the project. The notice shall include the reason for termination.
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Observations
The facility failed to document a written involuntary termination notice in one of one client records reviewed during the annual licensing inspection on February 20, 2018. Client #7 was admitted on October 16, 2017 and was involuntarily terminated on February 13, 2018. There was no written involuntary termination notice in client record #7.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
To ensure that this does not occur in the future, as of 2/26/2018 the following steps have been implemented. The facility director has retrained all clinical staff on the paperwork that must be completed prior to discharge. Prior to involuntary discharge, according to regulation 709.33 (a), the client will receive a written letter from the counselor that will include the reason for termination. The client shall have the opportunity to request reconsideration of the decision to terminate treatment per regulation 709.33 (b) a copy of this letter will be placed in the client's chart. This will be monitored on a quarterly basis by the clinical supervisor. |
709.34 (c) (1) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(c) To the extent permitted by State and Federal confidentiality laws, the project shall file a written unusual incident report with the Department within 3 business days following an unusual incident involving:
(1) Physical or sexual assault by staff or a client.
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Observations
The facilty failed to notify the Department of an unusual incident involving police presence within 3 business days.There was police presence at the facility on February 13, 2018. There was no unusual incident report documented for this incident.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
As of 3/6/2018 the facility director has distributed a memorandum to all staff instructing them on the protocol for completing unusual incidents reports that pertain to regulation 709.34 will be reported via fax and /or email to the Department of Drug and Alcohol Programs by the facility director with the assistance of the administrative assistant within (3) business days of the incident. This will be monitored monthly by the facility director and will also addressed during quarterly staff meetings. |