INITIAL COMMENTS
|
This report is a result of an on-site licensure renewal inspection conducted on December 17, 2007 through December 19, 2007 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, The Consortium 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 and a plan of correction is due on January 23, 2008.
|
Plan of Correction
|
704.11(a)(3) LICENSURE Training Feedback
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(3) A mechanism to collect feedback on completed training.
|
Observations
Based on a review of personnel and training records, the facility failed to document training feedback in two of two records reviewed, #7 and 8.
|
Plan of Correction
L 0059
Staff Training Feedback
Staff Training feedback documentation has been organized in a single staff directory. The single storage of documentation enables management to monitor feedback in an efficient and comprehensive manner
RESPONSIBLE: All staff to submit training feed back forms on any training received to their supervisor with a copy to Human Resources. Clinical Director & Facility Director will train staff on their responsibility in the staff training protocol.
TIME LINES: Centralized training feed back book has been created as of 1-21-08. Submission for training is effective as of 1-21-08. Clinical Director & Facility Director will present/remind staff of their responsibility by 1-22-08
MONITORING: Clinical Supervisors to monitor documentation submission for their staff on an ongoing basis. Human Resources will monitor compliance to an ongoing basis
|
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.
|
Observations
Based on a physical plant inspection conducted on December 19, 2007, the facility failed to demonstrate that the smoke detectors between the first and second floor, where the program operates, were interconnected.
|
Plan of Correction
P P253
Fire Safety smoke detector
The second floor did not have an interconnected smoke detector.
RESPONSIBLE: The Director of Facilities will install an interconnected smoke detector for the second floor of the facility.
TIME LINES: The interconnected smoke detector will be installed by 2-28-08
MONITORING: The Consortium Facilities Consultant will monitor completion of this installation.
|
705.28 (d) (1) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(1) Conduct unannounced fire drills at least once a month.
|
Observations
Based on a review of the fire drill record, the facility failed to document that fire drills were conducted during the following months: August 2007, September 2007, October 2007 and November 2007.
|
Plan of Correction
P P273
Fire Safety Fire Drills
The facility fire drills were not conducted for several months in 2007. The lapse in formalized documented fire drills was due to Facility Staff change. The Consortium Director of Facilities has developed a monthly fire drill schedule that will insure at least 1 fire drill per month occurs on an on going basis
RESPONSIBLE: The Director of Facilities will deliver at least one fire drill per month and will document accordingly.
TIME LINES: The monthly fire drill process was initiated 1-1-08
MONITORING: The Consortium Facilities Consultant will monitor compliance. The Facility Director will receive copies of the monthly fire drill documentation.
|
705.28 (d) (5) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(5) Prepare alternate exit routes to be used during fire drills.
|
Observations
Based on a review of the fire drill logs, the facility failed to document which exit routes were utilized in five of six months where fire drills were conducted, March 2007, April 2007, May 2007, June 2007 and December 2007.
|
Plan of Correction
Fire Safety Fire Drill Exit Routes
The facility fire drills did not consistently document exit routes. The Consortium Director of Facilities has developed a new and improved monthly fire drill log that will document exit routes. This documentation will help insure that upcoming fire drills will comply with the standard calling for alternative exit routes on the monthly fire drill process.
RESPONSIBLE: The Directory of Facilities will implement the new and improved fire drill form for the February 2008 fire drills forward.
TIME LINES: The monthly fire drill log will be initiated 2-1-08
MONITORING: The Consortium Facilities Consultant will monitor compliance. The Facility Director will receive copies of the monthly fire drill documentation.
|
709.22(e)(3) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
(3) A statement disclosing the names of officers, directors and principal shareholders, where applicable.
|
Observations
Based on a review of the 2007 annual report, the facility failed to include a statement disclosing the names of officers and directors of the project.
|
Plan of Correction
Governing Body
The annual report was modified to include the names of the Board Members directly in the document (Annual Report)
RESPONSIBLE: Facility Director is responsible for the format modification
TIME LINES: Completed 12-31-07
MONITORING: Facility Director will insure that Annual Report format remains modified for future submissions.
|
709.26(e) LICENSURE Personnel Management
709.26. Personnel management.
(e) The project director shall develop written policies on employe rights and demonstrate the project's efforts toward informing staff of the following:
|
Observations
Based on a review of personnel records, the facility failed to document that employees were made aware of their rights pursuant to Chapter 709.26(e)(2) and (3) in five of six records reviewed, #3, 5, 6, 7 and 8.
|
Plan of Correction
L 0233
Personnel Management
Management will demonstrate and document that employees are aware of their rights as per Chapter 709.26. Employees will document that they are aware of their rights in the new employee orientation process.
RESPONSIBLE: Director of Human Resources is responsible to insure that the new employee orientation documentation includes notification of employee rights. Supervisors are responsible to insure that all new employees are oriented with the required information and that they acknowledge as such in the documentation
TIME LINES: New Employee orientation form will be modified to include the required information by 1-30-08. Supervisors will insure all new employees document that they have been informed of their rights.
MONITORING: Director of Human resources will monitor compliance of this standard.
|
709.32(c)(3) LICENSURE Medication Control
709.32. Medication control.
(c) The project shall have a written policy regarding medications used by clients which shall include, but not be limited to:
(3) Inspection of storage areas.
|
Observations
Based on a review of the facility policy and procedure and documentation of inspection records, the facility failed to document monthly inspections of the medication storage areas prior to October 2007. The facility's policy and procedure stated that facility staff would conduct monthly inspections of the storage areas. Monthly inspections were not documented prior to October 2007.
|
Plan of Correction
Medication Control
The policy book stated that inspection of storage areas was conducted on a monthly basis but the documentation showed 90-day inspections. The practice has been modified to conform to the 30-day inspection cycle.
RESPONSIBLE: The OTP Head Nurse is responsible for the inspection of drug storage areas and has already conformed to the 30-day inspection cycle.
TIME LINES: 30-day inspection of drug storage areas was implemented 12-31-07
MONITORING: The OTP Head Nurse will monitor conformance and submit monthly reports to the OTP Medical Director & Facility Director who will also monitor
|
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.
|
Observations
Based on a review of client records, the facility failed to document individual treatment plans with goals stated in terms of measurable criteria in nine of fourteen client records reviewed, #1, 2, 3, 5, 6, 8, 9, 18 and 19.
|
Plan of Correction
Treatment Plan measurable criteria
Some treatment plans were observed that did not have goals stated in measurable terms. This issue will be addressed in the staff training and supervision process.
RESPONSIBLE: The clinical staff are required to utilize measurable terms for the documentation of treatment plan goals for consumers. Clinical Supervisors are responsible to review on going treatment plans and to provide specific supervision on individual compliance. The Clinical Director & Facility Director are responsible to conduct specialized staff training on treatment plans & goal formulation
TIME LINES: The Clinical Director & Facility Director will conduct specialized staff training on treatment plans & goal formulation by 2-15-08. Clinical Supervisors will review on going treatment plans to provide specific supervision on individual compliance starting 2-15-08. : The clinical staff are required to utilize measurable terms for the documentation of treatment plan goals for consumers effective 2-15-08
MONITORING: The Facility Director will monitor the staff training process to insure treatment plan & measurable goals training was accomplished. The Clinical Supervisors will monitor all treatment plans to insure compliance. The Clinical Director will monitor the performance of the Clinical Supervisors oversight of the treatment planning process
|
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
|
Observations
Based on a review of client records, the facility failed to document an assessment of the client's progress in relationship to the previously stated goals of the treatment plan in 11 of 14 records reviewed, #1, 2, 3, 4, 5, 6, 8, 10, 13, 17 and 18.
|
Plan of Correction
Treatment Plan measurable criteria
Some treatment plans updates were observed that did not have progress (or lack thereof) documented. This issue will be addressed by the re-design of the treatment update instruments and by clinical staff training and supervision process.
RESPONSIBLE: The clinical staff are required to document progress in the treatment plan update process. Clinical Supervisors are responsible to review on going treatment plans and to provide specific supervision on individual compliance. The Clinical Director & Facility Director are responsible to develop an instrument modification which will better capture progress and to conduct specialized staff training on treatment plans & goal formulation
TIME LINES: The Clinical Director & Facility Director will conduct specialized staff training on the treatment update planning by 2-15-08 as well as the development/implementation of the treatment planning update worksheet. Clinical Supervisors will review on going treatment plans to provide specific supervision on individual compliance starting 2-15-08. : The clinical staff are required to utilize progress updates for the documentation of treatment plans for consumers effective 2-15-08
MONITORING: The Facility Director will monitor the staff training process to insure treatment plan & progress updates training was accomplished. The Clinical Supervisors will monitor all treatment plans to insure compliance. The Clinical Director will monitor the performance of the Clinical Supervisors oversight of the treatment update planning process
|