INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on February 27, 2012 to February 28, 2012 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, Clinical Outcomes Group Incorporated 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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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.
The findings include:
On February 28, 2012, three personnel records requiring documentation of fire extinguisher training were reviewed. The facility did not provide documentation that they instructed staff in the use of the fire extinguisher upon staff employment in one of three personnel records reviewed, specifically, personnel record # 6.
Employee # 6, the medical director, was hired on September 9, 2010. Employee # 6 was due to complete fire extinguisher training upon employment. However, personnel record # 6 did not include documentation of fire extinguisher training as of February 28, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on February 28, 2012 from approximately 10:00 A.M. to 10:15 A.M.
This is a repeat citation. The facility was cited on January 4, 2011 for noncompliance with this standard.
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Plan of Correction
The facility director will provide the medical director (employee #6) with the fire estinguisher manual in order to assist in explaining the operation of our current fire estinguishers. The facility director will then review the manual with the medical director. The medical director will then be required to explain to the facility diretor how to use the fire estinguisher if necessary. This will be completed with two weeks or by March 15, 2012. The medical director will document with his signature in the staff training manual when said training is complete. |
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 are trained to perform assigned tasks during emergencies.
The findings include:
On February 28, 2012, three 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 provide documentation of the completion of emergency training in one of three personnel records, specifically, personnel record # 6.
Employee # 6, the medical director, was hired on September 9, 2010. Employee # 6 was due to complete emergency training upon employment. However, personnel record # 6 did not include documentation of emergency training as of February 28, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on February 28, 2012 from approximately 10:00 A.M. to 10:15 A.M.
This is a repeat citation. The facility was cited on January 4, 2011 for noncompliance with this standard.
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Plan of Correction
The facility director will provide the medical director (employee #6) with the emergency manual for staff within two weeks or by March 15, 2012. The manual will be reviewed with the medical director to ensure that he understands the clinics policies for emergency situations. The medical director will document with his signature that he recieved the manual and training regarding emergency situations within the facility within two weeks or by Marh 15, 2012. |
709.22(e) 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:
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Observations
Based on an interview with the facility director, the governing body failed to make available to the public an annual report.
The findings include:
The facility's 2010 to 2011 fiscal year ended on June 30, 2011. On February 27, 2012 and February 28, 2012 the Licensing Specialist asked to see a copy of the facility's annual report for the facility's 2010 through 2011 fiscal year. The facility was not able to present a copy of an annual report for the facility's 2010 through 2011 fiscal year.
The findings were confirmed during an ongoing dialogue with the facility director on February 28, 2012 from approximately 9:30 A.M. to 12:00 P.M.
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Plan of Correction
The project director will work with the Board of Directors by May 21, 2012 in developing and annual report for the facility for the year 2010-2011. By June 21, 2012, the project director will have completed an anuual report for the facility for 2010-2011 and have it readily available for review.
In order to ensure continuity of this effort, the Board of Directors will be asked at their next meeting (4/16/2012) to approve a motion that requires the Executive Director to produce an annual report in compliance with the requirements of licensing. Compliance will be monitored by the President of the Board of Directors. |
709.23(b) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
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Observations
Based on a review of the facility's administrative documentation, the project director failed to present goals and objectives for the July 2011 through June 2012 fiscal year to the governing body.
The findings include:
The facility's administrative documentation was reviewed on February 27, 2012 through February 28, 2012. On February 27, 2012 and February 28, 2012, the Licensing Specialist asked to see documentation that the project director presented the goals and objectives for the July 2011 through June 2012 fiscal year to the governing body. The facility was unable to provide documentation showing that the goals and objectives for the July 2011 through June 2012 fiscal year were presented to the governing body.
The findings were confirmed during an ongoing dialogue with the project director on February 28, 2012 from approximately 12:00 P.M. to 12:30 P.M.
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Plan of Correction
The project director was hired January 1, 2012. As part of the new position, he will complete a plan for the agency to include goals and objectives for the remainder of the 2012 fiscal year. This plan will be reviewed and approved by the Board of Directors. By June 30, 2012 the current project director will complete an overall plan for the project to include goals and objectives for the facility. This plan will be made available for review. To ensure compliance, the project director will complete this same process with the Board of Directors for the fiscal year 2012-2013. This plan will be completed by July 30, 2012. The Board of Directors will review both plans and this review process will be dpocumented within the board meeting minutes to ensure compliance. |
709.23(b)(1) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of the facility's administrative documentation, the facility failed to develop goals and objectives for the July 1, 2011 to June 30, 2012 fiscal year.
The findings include:
On February 28, 2012, the Licensing Specialist asked to see a copy of the facility's goals and objectives for July 1, 2011 to June 30, 2012 fiscal year. The facility was unable to present a copy of the facility's goals and objectives for July 1, 2011 to June 30, 2012 to that included time frames and available resources.
The findings were confirmed during an ongoing dialogue with the project director on February 28, 2012 from approximately 12:00 P.M. to 12:30 P.M.
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Plan of Correction
The project director will omplete the annual plan for the project to include goals and objectives. These goals and objective will include time frames that goals are liekly to be obtained and the resources to aid in the accomplishment of said goals. This plan will be reviewed as necessary by the project director to ensure compliance and need to change or update the plan. The plan will be reviewed quarterly with the Board of Directors to ensure compliance. This review process with the Board of Diretors will be documented within the board meeting minutes to ensure compliance of the project plan. The goals and objectives will be developed and presented to the Board at their July 2012 meeting (or next available scheduledmeeting), with the quarterly report on the status of the goals and objectives due with the first quarterly report following on Oct. 31, 2012. |
709.23(b)(3) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on a review of the facility's administrative documentation, the facility failed to present a performance report summarizing the progress towards meeting goals and objectives to the governing body.
The findings include:
On February 28, 2012, the Licensing Specialist asked see the facility's performance report summarizing the progress towards meeting the goals and objectives from the July 1, 2010 to June 30, 2011 fiscal year. A performance report summarizing the progress towards meeting goals and objectives for the July 1, 2010 to June 30, 2011 was not presented for review.
The findings were confirmed during an ongoing dialogue with the project director on February 28, 2012 from approximately 12:00 P.M. to 12:30 P.M.
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Plan of Correction
The project director will review the goals of the agency once complete and complete and annual report summarizing accomplishments for the year and areas that need continued development. At the time of this review the project director will evaluate that goals that need to continue and the goals that were obtained by the agency. The annual review will be completed by Sept 30, 2012 for the fiscal year ending June 30, 2012. This annual report will be completed each year within three months after the end of the fiscal year. The project director will complete this same process each year. This annual report will then be reviewed with the Board of Directors for approval. This review and approval with be documented within the board meeting minutes to ensure compliance with this citation. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on an interview with the facility director, the facility failed to provide an annual audit of financial activities associated with the project's drug/alcohol abuse services.
The findings include:
The facility's 2010 to 2011 fiscal year ended on June 30, 2011. On February 27, 2012, the Licensing Specialist asked to see a copy of the facility's independent annual audit of financial activities associated with the project's drug/alcohol abuse services for the facility's 2010 through 2011 fiscal year. An annual audit of financial activities associated with the project's drug/alcohol abuse services for the facility's 2010 through 2011 fiscal year was not presented for review.
The findings were confirmed during an interview with the facility director on February 27, 2012 at approximately 9:30 A.M.
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Plan of Correction
The clinic's Fiscal Director will work with the independent public accountant in completing the annual audit for 2010-2011. This audit will be complete by June 30, 2012. The audit will be made available for review to ensure compliance. The request for this audit has been sent. If the auditor agrees to conduct a combined audit for the 2010- 2012 years, then the audit will be completed by June 30, 2012
In order to ensure that audits are obtained annually, the Board will be presented with a motion at the April 16, 2012 meeting that requires the Executive Director to seek and obtain an annual audit from an independent public accountant and will document this directive in their minutes. The President of the Board of Directors will monitor for compliance, that annual audits are conducted. |
709.26(d)(5)(i) LICENSURE Personnel Management
709.26. Personnel management.
(d) The personnel records shall include, but not be limited to:
(5) Work performance evaluation including the following:
(i) Individual staff performance shall be evaluated at least annually.
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Observations
Based on a review of personnel records and the facility's policy and procedures, the facility failed to document an initial work performance evaluation for all staff in accordance with the facility's policies and procedures.
The findings include:
The facility's policy titled: "Work Performance Evaluation Policy," states:
"All employees shall have work performance evaluations conducted by their immediate supervisor.
1. Initial evaluations on all new personnel shall be made in writing by their respective supervisor following six (6) months employment to determine employee effectiveness and areas needed for development and improvement.
2. Evaluations for all personnel will take place yearly (+/- one month) based upon hire date.
3. Employees will be evaluated at a minimum of yearly by their immediate supervisor."
On February 28, 2012, three personnel records requiring documentation of a work performance evaluation were reviewed. The facility did not document an initial work performance evaluation in three of three personnel records reviewed, specifically, personnel records # 3, 4, and 5.
Employee # 3, a counselor, was hired December 1, 2010. An initial work performance evaluation was due June 2011. However, personnel record # 3 did not include documentation of an initial work performance evaluation as of February 28, 2012.
Employee # 4, a counselor, was hired December 1, 2010. An initial work performance evaluation was due June 2011. However, personnel record # 4 did not include documentation of an initial work performance evaluation as of February 28, 2012.
Employee # 5, the administrative assistant, was hired June 1, 2011. An initial work performance evaluation was due December 2011. However, personnel record # 5 did not include documentation of an initial work performance evaluation as of February 28, 2012.
The findings were confirmed during an ongoing dialogue with the facility director on February 28, 2012 from approximately 10:00 A.M. to 11:00 A.M.
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Plan of Correction
The faciltiy director will complete work performance evaluations for current staff #3, 4 and 5 with the next three months or by June 30, 2012. This evaluation will be completed for each of these staff menbers to assess and determine employee effectiveness and areas of developemtn and improvement. This evaluation will be documented and placed in their employee file for review.
To ensure continued compliance,the facility director will complete a work performance evaluation on all new hires within the first six-months of employment. and annually for all employees (+ or- one month from the date of hire) to determine employee effectiveness and areas of development and improvement. This evaluation will be documented and placed in their employee file for review. |
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 obtain an informed and voluntary consent from the client for the disclosure of information.
The findings include:
On February 28, 2012, five client records requiring documentation of informed and voluntary consent were reviewed. The facility released information without the client's consent in three of five client records reviewed, specifically, client records # 2, 3, and 5.
Client record # 2 contained one Eligibility Verification System form dated 2/23/12 in which the facility released information about the client to a government agency, but the facility did not have a signed consent from the client to release the information.
Client record # 3 contained one Eligibility Verification System form dated 1/24/12 in which the facility released information about the client to a government agency, but the facility did not have a signed consent from the client to release the information.
Client record # 5 contained one Eligibility Verification System form dated 1/24/12 in which the facility released information about the client to a government agency, but the facility did not have a signed consent from the client to release the information.
The findings were confirmed during an ongoing dialogue with the facility director on February 28, 2012 from approximately 2:30 P.M. to 3:00 P.M.
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Plan of Correction
The facility director will have clinical staff and adminstrative staff obtain informed and voluntary consent of all current clients. The staff members will have all current clients sign a specific release of information for the government agency so that information about the client can be obtained through the eligibility verification system. Staff will ensure the clients #2,3, and 5 have the specific consent within their file for review. This will be completed effective immediately. Beginning 2/29/12, all clinical staff began having all current clients and new clients sign a specific release of information giving the facility permission to verify eligibility of medical insurance. The facility director will montitor this monthly to ensure compliance. By 3/29/2012, the facility will be in full compliance of this citation. |