INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on March 20, 2012, by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Rehab Management 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
Based on a review of the 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 TB/STD and other health related topics training using a Department approved curriculum within the required timeframe.
The findings include:
The SRFSR was reviewed on March 20, 2012. The SRFSR failed to include documentation that employee # 5, had received HIV/AIDS and / or TB/STD training as required.
Employee # 5, an Administrative Coordinator, was hired on January 26, 2009. Employee # 5 was required to have completed both the HIV/AIDS and TB/STD trainings as of January 26, 2011. As of March 20, 2012, there was no documentation on the SRFSR that employee # 5 completed HIV/AIDS training using a Department approved curriculum.
Documentation on the SRFSR indicated that on on December 14, 2011, employee # 5 completed 4 hours of training using a department approved TB/STD curriculum. However, the TB/STD training was late as it was completed outside of the required two year time frame.
The findings were confirmed by the Facility Director during the exit interview.
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Plan of Correction
Employee #5 will be given the proper Pennsylvania Department of Health HIV/AIDS and TB/STD training within by the correction action date. Employee number #5 has already completed the required 4 hours of mandated TB/STD training hours and will be receiving the HIV/AIDS training by the corrective action date.
The Site Director will inform any newly hired staff of the mandatory HIV/AIDS and TB/STD trainings and the required time frames for completion of the trainings (1 year for clinical staff and 2 years for support staff). It will the individual employee's responsibility to complete the training within the required time frames and to forward a copy of the certificate to the Site Director and the Human Resources Department.
The Human Resources Department will monitor the progress by contacting the employee at 6 months and then again at 9 months from the date of hire for clinical staff and at 12 months and 18 months from the date of hire for support staff to ensure that the trainings were completed and that the certificates were turned in. If the employee has not completed at 9 months (clinical staff) and 18 months (support staff) then HR will instruct them to register and ensure that they complete with in the mandated time frames of 12 months for clinical staff and 24 months for support staff and provide the certificate as verification.
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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
Based upon a review of documentation of employee Cardio Pulmonary Resuscitation (CPR) certification, staffing schedules, and the facility's hours of operation, the facility failed to ensure that at least one person trained in CPR was onsite during all hours of operation.
The findings include:
The facility's hours of operation, staffing schedules and CPR certifications were reviewed on March 20, 2012. The hours of operation are listed as Monday - Friday, from 9 AM to 9 PM, with hours on Saturday by appointment.
Staffing schedules for the weeks of February 21, 2012, to March 20, 2012, revealed the following:
Employee # 2 worked Monday to Friday, from 10 AM - 6 PM.
Employee # 3 worked Monday to Friday, from 11 AM - 7 PM.
Employee # 4 worked Monday to Friday, from 1 PM - 9 PM.
Employee # 5 worked Monday to Friday, from 9 AM - 5 PM.
Employee # 6 worked Monday to Friday, from 12 AM - 8 PM.
Employee # 7 worked Monday to Friday, from 1 PM - 9 PM.
Employee # 8 worked Monday to Thursday, from 1 PM - 8 PM and Friday from 5 PM - 8 PM
Documentation of CPR certifications were reviewed for seven of seven staff members who are designated to provide CPR coverage. Four of seven staff members, specifically #'s 3, 5, 7, and 8, did not have current CPR certification.
Based on the staffing schedules, employee # 5 was the only employee who worked Monday to Friday, 9 AM - 10 AM, from February 21, 2012 to March 20, 2012. However, since employee # 5 does not have a current CPR certification, the facility failed to ensure that at least one person trained in these skills was onsite during all of the project's hours of operation.
The findings were confirmed by the Facility Director during the exit interview.
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Plan of Correction
Upon further review of the schedule for the dates in question, the Facility Director was on site 14 out of 30 days in question at 9 a.m. covering all times with CPR coverage (leaving 16 days uncovered.) To fix this discrepency, the Site Director will adjust his schedule to make sure that all shifts are perfectly covered with staff that are CPR certifed. Further, one more staff member will be CPR certified who is typically on site at 9 a.m. to provide the office with four full time staff members with CPR coverage.
The Site Director maintains a log with copies of CPR qualified staff members certifications, along with their dates of expiration. Staff members are required to retrain before their dates of expiry and the project offers staff opportunties to retrain well before these dates. If a staff cannot make a training or there is a lapse, workload schedules will have to be altered to maintain coverage until staff members are retrained as required by the project.
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705.24 (3) LICENSURE Bathrooms.
705.24. Bathrooms.
The nonresidential facility shall:
(3) Have hot and cold water under pressure. Hot water temperature may not exceed 120F.
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Observations
Based upon the physical plant inspection, the facility failed to ensure that the hot water temperature did not exceed 120 degrees Fahrenheit.
The findings include:
The physical plant inspection was conducted on March 20, 2012. The facility provided one bathroom with five sinks for female clients, staff and visitors. The hot water from the 4th sink from the right registered 132 degrees Fahrenheit. The facility provided one bathroom with two sinks for male clients, staff and visitors. The hot water from the sink on the right registered 132 degrees Fahrenheit. The hot water exceeded 120 degrees Fahrenheit.
The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
The facilty director will address this issue with the landlord and have him adjust the water heat to make certain that it does not exceed 120 degrees Fahreheit by the corrective action date.
The facility director or designee will check the water temperatures on a daily basis and document those temperatures in a log book. Should the temperature exceed 120 degrees Fahrenheit on any day, a warning sign will be posted and the landlord will be notified immediately to correct the problem. |
705.28 (b) (1) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(1) Maintain a minimum of one operable automatic smoke detector on each floor, including the basement and attic.
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Observations
Based upon the physical plant inspection, the facility failed to maintain a minimum of one operable automatic smoke detector on each floor in the facility.
The findings include:
The physical plant inspection was conducted on March 20, 2012, with the Facility Director present. The Licensing Specialist was unable to find a smoke detector inside the facility.
The Facility Director confirmed that no smoke detector was present.
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Plan of Correction
The facility director has already purchased and installed three smoke detectors in the facility.
During weekly physical plant inspections the site director or designee will make certain the smoke detectors are present and intact. Further, the smoke directors will be utilized (on a rotating basis) to sound the facility fire drills. Their batteries will be changed monthly to keep them operational. |
705.28 (b) (2) LICENSURE Fire safety.
705.28. Fire safety.
(b) Smoke detectors and fire alarms. The nonresidential facility shall:
(2) Place the smoke detector in a common area or hallway. All detection devices shall be interconnected.
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Observations
Based upon the physical plant inspection, the facility failed to place a smoke detector in a common area or hallway.
The findings include:
The physical plant inspection was conducted on March 20, 2012, with the Facility Director present. The Licensing Specialist was unable to find a smoke detector in any common areas or hallways.
The Facility Director confirmed that no smoke detector was present.
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Plan of Correction
The facility director has already installed three smoke detectors in the facility, and had purchased them and showed them to the inspector on the date of inspection 3/20/12.
The facility director will conduct weekly physical plant inspections that will include checking to ensure that the smoke detectors are present. During regular fire drills the smoke detectors will be utilized (on a rotating basis) as the means to sound the drill and their batteries will be changed monthly.
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705.28 (c) (1) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential 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, there shall be an additional fire extinguisher for each 2,000 square feet or fraction thereof.
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Observations
Based upon the physical plant inspection and information provided by the Facility Director, the facility failed to maintain at least one ABC rated fire extinguisher per each 2000 square feet of floor space or fraction thereof.
The findings include:
The physical plant inspection was conducted on March 20, 2012.
The facility maintained three (3) portable ABC rated fire extinguishers, which was sufficient for 6000 square feet of floor space. However, the Facility Director informed the Licensing Specialist that the facility occupied approximately 7800 square feet. Therefore, the facility was required to maintain four (4) portable ABC fire extinguishers.
The findings were confirmed by the Facility Director during the inspection and again during the exit interview.
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Plan of Correction
The facility director will obtain one more fire extinguisher and have it installed by the corrective action date. The installation date is May 2, 2012 and the extinguisher has already been ordered.
The facility director will during his weekly physical plant inspection make certain that the fire extinguishers are present and intact and that their expiration dates are still valid. If he finds that this is not the case, he will order a new fire extinguisher immediately to maintain the four fire extinquishers required. |
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
Based upon a review of the facility Fire Drill Log, the facility failed to provide documentation that verified that the fire alarm or smoke detector was operative.
The findings include:
The Fire Drill Log for the months of March 2011 to February 2012, was reviewed on March 20, 2012. It should be noted that the facility moved from its previous location and into its current site on March 5, 2012. Therefore, the Fire Drill Log that was reviewed applied to the former site. While the facility had an exception letter for the previous site that permitted for the use of an alternate means of announcing its fire drills, the facility failed to provide documentation that demonstrated that the fire alarm system had been tested and was operational.
The Facility Director confirmed that the facility did not have any documentation that confirmed that the fire alarm system was tested and operational.
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Plan of Correction
The facility director will provide documention that the fire alarm system was tested and operational. Further, the facility director will apply for an exception letter for the new location that will grant an altenative means of announcing fire drills.
The facility director maintain a log and require yearly tests of the fire alarm system and have documentation provided to him in writing regarding this by the landlord. |
709.25(b) LICENSURE Fiscal Management
709.25. Fiscal management.
(b) Projects shall develop a service fee schedule which shall be posted in a prominent place.
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Observations
Based upon the physical plant inspection, the facility failed to post a service fee schedule in a prominent place.
The findings include:
The physical plant inspection was conducted on March 20, 2012, with the Facility Director present. The Licensing Specialist was unable to locate a service fee schedule that was posted in a prominent place.
The Facility Director confirmed that a service fee schedule was not posted.
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Plan of Correction
The fee schedule was put in a prominent place on 3/20/12. Due to a recent move, this was an oversight and has since been remedied. |
709.28(a)(1) LICENSURE Confidentiality
709.28. Confidentiality.
(a) A written procedure shall be developed by the project director which shall comply with 4 Pa. Code 255.5 (relating to projects and coordinating bodies: disclosure of client-oriented information). The procedure shall include, but not be limited to:
(1) Confidentiality of client identity and records.
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Observations
Based on a review of the facility policy and procedure manual, the facility failed to document a confidentiality policy and procedure compliant with 4 Pa. Code subsection 255.5.
The findings included:
4 Pa. Code subsection 255.5 (a)(6), states: "Projects may disclose with the consent of a client, in writing, the information to employers of a client to further the rehabilitation of a client; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Such information shall be limited to whether the client has or is receiving treatment with the project."
The facility policy and procedure manual was reviewed as part of the annual onsite licensing inspection of March 5 - 6, 2012. Policy # 60,006, section C, subsection 2, letter f, exceeded 4 Pa. Code subsection 255.5 (a)(6), as it allowed for the following: "Life Management may disclose with the client's consent, the information to employers of a client to further the client's rehabilitation; or, to a prospective employer who affirmatively expresses that information is sought to enable the employer to engage the client as an employee. Information released shall be limited to that provided for in subsection 4.a. in this section."
Subsection 4.a. states: " Nature of Client Information to be Disclosed. a. Information released to judges, probation or parole officers, insurance company, health or hospital plan or government officials, pursuant to section C.2.a-i of this section, is for the purpose of determining the advisability of continuing the client in treatment with Life Management and shall be restricted to the following:
i. Whether or not the client is in therapy
ii. The prognosis of the client
iii. The nature of the project
iv. A brief description of the client's progress
v. A short statement as to whether the client has relapsed into drug or alcohol abuse and the
frequency of such relapse."
The project's Confidentiality policy permits for the release of information under ii, iv, and v, which is restricted under 4 PA Code 255.5(a)(6).
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Plan of Correction
The Executive Director of Rehab After Work will change the policy & procedures section in our manual (#66006) to reflect that "information specifically released to employers will be limited to whether a client has or is receiving treatment with the project". This will be circulated to all offices.
All staff will be required to attend a 6 hour training on Confidentiality (255.5) on 4/13/2012 presented at our Phoenixville location. This policy addendum will be reviewed for all staff as part of the training.
Site directors will perform random, monthly charts audits to ensure that this policy change is being reflected by all clinicians.
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709.28 (c)(1) 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 shall include, but not be limited to:
(1) Name of the person, agency or organization to whom disclosure is made.
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Observations
Based upon a review of client records, the facility failed to obtain informed and voluntary consents that included the name of the person, agency or organization to whom disclosure is made.
The findings include:
Nine client records requiring documentation of informed consent forms were reviewed on March 20, 2012. Two of nine records, specifically record #'s 4 and 8, contained consent forms that failed to include the name of the person, agency or organization to whom disclosure was to be made.
Client # 4 was admitted on December 7, 2011, and was still an active client on the day of inspection. Record # 4 contained a consent form, signed and dated by the client on December 7, 2011, that failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
Client # 8 was admitted on July 11, 2011, and was discharged on September 9, 2011. Record # 8 contained a consent form, signed and dated by the client on July 11, 2011, that failed to include the actual name of the person, agency or organization to whom disclosure was to be made.
The findings were reviewed with the Facility Director during the exit interview.
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Plan of Correction
The facility director will review with staff members regarding the importance of completing informed consent forms and do a training on this during a staff meeting on 4/19/12. He will then check charts on a monthly basis to ensure compliance, as well as speak with clinicians regarding this issue during supervision. If problems continue to arise he will work with clinicians individually, and do further follow up trainings as needed. |