INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 21, 2013 to February 22, 2013 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Family Service Association of Bucks County 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)(3) & (4) LICENSURE Training types and amounts
704.11. Staff development program.
(c) General training requirements.
(3) At least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff.
(4) An individual who holds more than one position in a facility shall meet the training requirement hours set forth for the individual's primary position. Subject areas shall be selected according to the individual's training plan. Primary position is defined as that position for which an individual was hired.
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Observations
Based on a review of the personnel records, the Staffing Requirements Facility Summary Report (SRFSR) completed by the facility on February 21, 2013 and an interview with the Executive Assistant, the facility failed to ensure that at least one-half of all training in this section shall be provided by trainers not directly employed by the project unless the project employs staff persons specifically to provide training for its organization and staff in 8 out of 12 personnel reviewed.
The findings include:
From February 21, 2013 to February 22, 2013, the SRFSR and five personnel records requiring documentation of training hours were reviewed. The facility did not ensure that at least one-half of all training hours for staff were completed with trainers not directly employed by the project for 8 of 12 personnel reviewed, specifically, personnel # 6,12, 13, 14, 15, 16, 17, and 18.
Employee # 6 is a counselor and was hired March 21, 2011. Only 7.50 hours of employee # 6's required 25 hours of training were completed by trainers not directly employed by the project.
Employee # 12 is a counselor and was hired July 24, 2007. Based on the SRFSR, only 3 hours of employee # 12's required 25 hours of training were completed by trainers not directly employed by the project.
Employee # 13 is a counselor and was hired January 10, 2011. Based on the SRFSR, only 9 hours of employee # 13's required 25 hours of training were completed by trainers not directly employed by the project.
Employee # 14 is a counselor and was hired January 6, 2010. Based on the SRFSR, only 8 hours of employee # 14's required 25 hours of training were completed by trainers not directly employed by the project.
Employee # 15 is a counselor and was hired March 21, 2011. Based on the SRFSR, only 7.50 hours of employee # 15's required 25 hours of training were completed by trainers not directly employed by the project.
Employee # 16 is a counselor and was hired May 2, 2007. Based on the SRFSR, none of employee # 16's required 25 hours of training were completed by trainers not directly employed by the project.
Employee # 17 is a counselor and was hired April 13, 2000. Based on the SRFSR, only 2 hours of employee # 17's required 25 hours of training were completed by trainers not directly employed by the project.
Employee # 18 is a counselor and was hired February 22, 2011. Based on the SRFSR, only 10 hours of employee # 18's required 25 hours of training were completed by trainers not directly employed by the project.
The findings were confirmed during an interview with the Executive Assistant on February 22, 2013 at approximately 10:30 A.M.
This is a repeat citation. The facility was cited on February 2, 2012 for noncompliance with this regulation.
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Plan of Correction
1) Clinical Supervisors will review training obtained by their direct report staff quarterly to ensure that staff are on track to complete at least one-half training by trainers external to the project as required and that they are on track with the balance of required annual training hours from either internal or external trainers for a combined 25 hours of training annually.
2) Staff will utilize Essential Learning to assist with obtaining external training hours.
3)Staff will sign an acknowledgement by April 30, 2013 that they will attend at least one-half hours of training provided by an external trainer and complete the balance of training hours required by an internal trainer or external trainer for a combined total of 25 training hours annually.
The project Facility Director will ensure tht the citation is corrected. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of personnel records, the facility failed to instruct staff in the use of the fire extinguisher upon staff employment in one of six personnel records reviewed.
The findings include:
From February 21, 2013 to February 22, 2013, six personnel records requiring documentation of fire extinguisher training were reviewed. The facility did not instruct staff in the use of fire extinguisher upon staff employment at the facility in one of six personnel records reviewed, specifically, personnel record # 10.
Employee # 10 is a counselor and was hired August 29, 2011. Employee # 10 was due to complete fire extinguisher training upon employment at the facility. However, employee # 10 did not complete fire extinguisher training until September 9, 2011.
The findings were confirmed during an interview with the Executive Assistant on February 22, 2013 at approximately 10:30 A.M.
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Plan of Correction
1)Clinical Supervisor will review that staff have been trained in use of the fire extinquisher during new hire's first week of employment with Family Service Association.
2) A memo from the Facility Director will be sent to all Clinical Supervisors and Human Resources emphasizing the importance of fire safety training and review of the new hire training form provided by HR for completion of this training with all new hires. Memo to be sent by April 1, 2013 and action to be implemented immedicately with all new hires going forward.
3) Clinical Supervisor will use their Outlook calendars to schedule a reminder within 3 days of the employee's hire to follow up on training.
The Clinical Supervisor of the new hire will be responsible to ensure that all new staff reporting to him/her complete the fire safety training within the fist week of hire. |
705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of personnel records, the facility failed to ensure that all personnel on all shifts were trained to perform assigned tasks during emergencies upon employment at the facility in one of six personnel records reviewed.
The findings include:
From February 21, 2013 to February 22, 2013, six personnel records requiring documentation that all personnel on all shifts had been trained to perform assigned tasks during emergencies were reviewed. The facility did not ensure that all personnel on all shifts completed emergency training upon employment at the facility in one of six personnel records reviewed, specifically, personnel record # 10.
Employee # 10 is a counselor and was hired August 29, 2011. Employee # 10 was due to complete emergency training upon employment at the facility. However, employee # 10 did not complete emergency training until September 14, 2011.
The findings were confirmed during an interview with the Executive Assistant on February 22, 2013 at approximately 10:30 A.M.
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Plan of Correction
)Clinical Supervisor will review that staff have had been trained in assigned tasks during emergencies and had the emergency training during new hire's first week of employment with Family Service Association.
2) A memo from the Facility Director will be sent to all Clinical Supervisors and Human Resources emphasizing the importance of emergency training and review of the new hire training form provided by HR for completion of this training with all new hires.
3) Clinical Supervisor will use their Outlook calendars to schedule a reminder within 3 days of the employee's hire to follow up on training.
Memo to be sent by April 1, 2013 and action to be implemented immedicately with all new hires going forward
The Clinical Supervisor of the new hire will be responsible to ensure that all new staff reporting to him/her are trained to perform assigned tasks and complete the Emergency training that includes fire extinquisher training within the fist week of hire.
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709.92(a)(1) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(1) Short and long-term goals for treatment as formulated by both staff and client.
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Observations
Based on a review of client records, the facility failed to document the long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan in seven of nine client records reviewed.
The findings include:
On February 22, 2013, nine client records requiring documentation of long-term goals for treatment as formulated by both staff and client in the individual treatment and rehabilitation plan were reviewed. The facility did not document the long-term goals for treatment in seven of nine records reviewed, specifically, client records # 2, 3, 4, 6, 8, 9, and 10.
Client # 2 was admitted December 13, 2012. The individual treatment and rehabilitation plan was completed on December 13, 2012, but it did not include documentation of the long-term goals for treatment as of February 22, 2013.
Client # 3 was admitted June 14, 2012. The individual treatment and rehabilitation plan was completed on June 14, 2012, but it did not include documentation of the long-term goals for treatment as of February 22, 2013.
Client # 4 was admitted June 15, 2012. The individual treatment and rehabilitation plan was completed on June 15, 2012, but it did not include documentation of the long-term goals for treatment as of February 22, 2013.
Client # 6 was admitted June 12, 2012. The individual treatment and rehabilitation plan was completed on June 11, 2012, but it did not include documentation of the long-term goals for treatment as of February 22, 2013.
Client # 8 was admitted September 18, 2012. The individual treatment and rehabilitation plan was completed on September 18, 2012, but it did not include documentation of the long-term goals for treatment as of February 22, 2013.
Client # 9 was admitted May 22, 2012. The individual treatment and rehabilitation plan was completed on May 22, 2012, but it did not include documentation of the long-term goals for treatment as of February 22, 2013.
Client # 10 was admitted June 7, 2012. The individual treatment and rehabilitation plan was completed on June 7, 2012, but it did not include documentation of the long-term goals for treatment as of February 22, 2013.
The findings were confirmed during an interview with one of the clinical supervisors and the facility director on February 22, 2013 at approximately 3:00 P.M.
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Plan of Correction
1) Clinical Supervisors will review during individual supervision with their direct reports the need to list long-term and short-term goals on the individual treatment and rehabilitation plan and the project Facility Directo/Director of Clinical Services will send a memo to all staff reinforcing the need for both long and short-term goals to be on all individual treatment and rehavilitation plans.
2) Clinical Supervisors will review all new treatment and rehabilitation plans for inclusion of long-term and short-term goals prior to signing off on those plans.
The project Facility Director will be responsible for correction of the citation.
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